June 2018

The business journal for doctors in private practice

On our special birthday, a big thanks to all our readers, sponsors, advertisers and contributors

InsIde: Celebrating a decade of Independent Practitioner Today, leading movers and shakers in the private practice world predict what’s in store for independent practitioners in ten years’ time, starting on page 26

Good ideas for boosting income thinking outside the box could bring you an increased income to combat insurers’ squeeze on your fees. accountant Susan Hutter shows you how P12

are you working for free?

How is the business side of your practice performing? try this quiz, compiled by Findlay Fyfe, to find out P14

what’s after Brexit?

if the Gmc calls... there is probably nothing anyone can do to entirely eliminate the risk of a GMc referral. Solicitor tania Francis advises what to do if that dreaded letter drops on your doormat P19

How will Brexit affect private healthcare? jane Braithwaite examines the areas that might catch out independent practitioners P16

editorial comment

Help to navigate change

Ten years ahead always seems so far away: it is only when you look back a decade you realise how fast 120 months can go by.

Back in 2008, things were very different in private practice. Yes, there was a recession, indemnity costs rising above the inflation rate and long-running verbal battles with insurers over fees.

But independent practitioners were much freer to get on with the job. Imagine the comparative absence of red tape. No revalidation as we know today. No quibbling CQC inspections. No data requirements from the Private Healthcare Information Network. And that’s just for starters.

Those were also the days before the HMRC toughened up on claims for motor and travel expenses and private doctors were not targeted by the taxman like they are now.

The Competition and Markets Authority was yet to be formed

and that long and unnecessarily painful probe into private healthcare was yet to come.

Groups were in their infancy, most private doctors did not have a website, ‘marketing’ was for entrepreneurs. And if you were considered among the best, you could be handsomely financially rewarded for signing up to a private hospital.

We’ve seen some big changes and as you read this 10th anniversary issue of this journal and consider what’s to come over the next decade, it is clear change will be ever more rapid.

So don’t miss an issue. What we said in our very first editorial comment, in June 2008, still holds true: ‘We aim to continue to provide you with the useful information and advice you need to help you run the most profitable business you can in these challenging and fast-changing times in private practice.’

ake this ‘slug’ of medicine

Medical historian Suzie Grogan unearths what today’s surgeons and predecessors were treating – and charging – in the 18th and 19th centuries P40

‘Hanging in there’ is key to investing How can you as an investor survive inevitable falls? patrick convey explains why you should keep calm and lean on your financial planner P46

Start a private practice: do you know what you pay tax on? capital gains tax is one of the less common taxes, but it can catch you out with its unexpectedness P50

doctor on the road: the ev charges ahead dr tony rimmer turns over the engine of the new nissan Leaf and finds it the most convincing and reasonably priced electric car available P52

Profits Focus: they’re in a healthy spot our unique benchmarking series turns its attention to the financial fortunes of dermatologists and oncologists P54

Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897

Head of design: Jonathan Anstee

INDEPENDENT PRACTITIONER TODAY the business journal for doctors in private practice

wHat iS tHe FUtUre oF Private Practice?

listen to an interview with accountant ray Stanbridge on our website

www.independent-practitioner-today.co.uk

Private sector’s future

By robin Stride

Massive change is on the way for independent practitioners across all areas of their work – but those who are serious about private practice can still expect to prosper.

That is a central message from ‘leading lights’ in the sector who we asked to mark Independent Practitioner Today’s 10th anniversary issue by predicting the landscape for our readers in a decade’s time.

Ten key areas to watch are:

1. Consultants

Insurers will cease to register consultants as individuals and will deal with properly established and regulated groups, according to a leading observer.

Accountant Ray Stanbridge said those who do not want to join groups will work through locum agencies or become employed by hospitals.

Positive and consistent clinical outcomes will be reflected by additional pay and those ‘not up to standard’ can expect a fee cut.

Independent Doctors Federation chief executive Sue Smith agreed more would be employed directly by hospitals, but she warned doctors to beware of swapping one set of bureaucratic shackles for another.

Commentators predict Harley Street will be challenged by less expensive more local locations while some consultants could work more internationally.

Rosemary Hittinger, associate adviser to the Federation of Independent Practitioner Organis ations, said: ‘The future will belong to practitioners who estab-

lish understandable and relevant measures, such as longterm sepsis rates or cancer survival rates, that prove the value they provide for their patients.’

2. Patients

Phone/text accessibility will be normal and patients will demand more information about alternatives and a more candid assessment of results.

Outcome measures, performance statistics and customer service are forecast to be increasingly greater determinants of where a patient will go than just a ‘name’. But the personal touch will remain the ‘holy grail’ with many patients, particularly for GPs.

3. Quality

Doctors will have to provide more comparable data about previous outcomes and so must do more auditing of results.

A vibrant practice will increasingly rely on showcasing quality through evidence. Patients are expected to make more informed choices about providers, using new website data.

4. Indemnity/insurance

Doctors in higher-risk areas of medicine will find it harder to get cover and some self-employed specialties will find it impossible. New models offering doctorspecific indemnity cover could help, but a continued shift is predicted away from defence bodies to insurance companies.

5. Self-pay

Competitive pricing will be needed as self-pay increases. But doctors will need to be on the ball to ensure billing and collection procedures work.

Private GP Dr Alix Daniel said: ‘The patient of 2028 will be a self-payer or have an insurance better tailored for modern care. There will be more self-referred patients and the idea of GP referral may have vanished by then.’

6. Hospitals and clinics

In 2028, there will be fewer beds and overnight stays. All hospitals will be embracing day-case treatment referrals.

New hospitals and clinic groups will emerge where people live and some existing ones will face huge pressure or be out of business.

More doctors will commit to contracts with shares in the organisation to try and control the care they deliver, while more online clinics will provide slicker ways to provide care.

7. Technology

Doctors will have more time to care for patients, thanks to revolutionary developments, while practice/patient communication will be more streamlined and totally secure.

Online booking will be normal, there will be integration between hospital systems and practice management systems, everything will be viewable on a hand-held

device and there will be robotic assistants.

Paper invoicing will be old hat, while a central online directory will hold all practitioners’ essential information in one place.

8. Private medical insurers

Groups are predicted to flourish as insurers look to this model of care. The lone practitioner will be an anachronism.

A continued push is expected to try and limit payments to private practitioners and more insurers are expected to come under bigger company umbrellas and take on their payment structures.

James Sherwood, Bupa UK director of health and benefits management, said: ‘Crucially, I expect insurers and hospital providers will seek to redesign processes and systems around the customer, enabling a simpler and enhanced experience when accessing and claiming for care.’

9. NHS

The NHS will offer more of its non-core business to the private sector. 2-5% of all NHS trust’s activity and income will be from insured and self-payers.

10. Regulation

More interventionist control from regulators like the GMC, Care Quality Commission and the Competition and Markets Authority appears inevitable, according to commentators.

It is predicted accountability will continue to have additional benchmarks set by regulators that can determine a practice’s success reputation and viability.

 See feature on page 26

Payslip slips lead to pension woes

By Edie Bourne

Independent practitioners who are also employed in the NHS have been advised to check their payslips after substantial numbers were been found to be incorrect.

The errors could lead to significant tax breaches if they are left unchecked, advisers told Independent Practitioner Today

Specialist financial planner Dr Benjamin Holdsworth, of Cavendish Medical, explained: ‘If you have not reviewed your payslip in a while, we would urge you to ensure you are being paid the correct amount. We have seen a high number of payslips from new clients this year with significant errors.

‘Although receiving the subsequent large repayment cheque can be gratifying for those missing out on their deserved income, the result can be grave conse -

quences in terms of pension contributions.

‘As we know, there are now harsh penalties for excess annual and lifetime pension savings. If you are on the wrong pay scale, your pension will be greater than projected and could lead to breaches of the tax-free savings limits. Any repayment paid as a lump sum could also trigger a tax charge.’

The new ‘tapered’ annual allowance means senior doctors earning over £150,000 from all sources – which includes their pension growth – face a significantly lower tax-free savings limit, down to just £10,000 a year in some cases.

The lifetime allowance currently stands at £1,030,000 – a hefty drop from its peak of £1.8m in 2011.

Dr Holdsworth added: ‘The pay slip is complex and mistakes can be easily missed by busy medical professionals or financial advisers not well versed in every NHS pay nuance.

‘But HM Revenue and Customs will not make allowances for doctors breaching tax limits even if through no fault of their own.

‘Computer-generated pay details often need a thorough “sense check” to ensure you receive what you deserve, stay on the right side of the taxman and can mitigate any liabilities due.’

new chief medical officer for Bupa

Former GP dr luke james (pictured right) is Bupa’s new medical director for uk Insurance, taking over from dr Steve Iley.

he said he looked forward to engaging with independent practitioners about how technology could drive quality, outcomes and experience improvements for customers.

dr james, who was Bupa health Clinics’ medical director for three years, added: ‘Recent events in the private sector have highlighted the need for accelerating the engagement and sharing of performance and outcome data between the nhS, private providers and insurers to ensure the highest quality care is delivered to our customers.’

his previous focus was on making sure the company’s 48 wellness centres and health clinics centres delivered a safe, compliant and competitive service.

Bupa said he would be responsible now for ensuring Bupa’s 2.3m insurance customers in the uk received safe high-quality care from the 25,000 consultants, over 8,000 therapists and 1,200 hospitals and clinics.

Healthcare firms miss out on R&D tax relief

Nearly 75% of healthcare firms could be eligible for research and development tax relief on new products and services, but only a third have ever claimed, according to a survey for a specialist tax relief firm.

Catax claimed 28% of healthcare businesses did not realise they could claim R&D tax relief if they developed a new product or service.

And just under a third of them reported ever claiming it – either because they did not think they qualified or they incorrectly believed it could cost them money.

Tax advisers said companies were throwing away millions of pounds a year because 72% of businesses in the sector had developed new products or business processes in the past two years, research shows.

The Government gives R&D tax relief to encourage innovation. But healthcare executives underestimate the value of the average small and medium enterprise R&D tax relief claim by £26,477, according to the survey by Censuswide.

Executives believed the average value to be just £19,523 when the true figure is £46,000 for firms in all sectors nationwide.

Catax said R&D did not even have to be successful to qualify and claims could be backdated at least two years.

Chief executive Mark Tighe commented: ‘The world of healthcare has long been at the forefront of technological development and that’s why it’s surprising that claim rates are this low, well below the national average.

‘Our research shows that by far the majority of firms in the healthcare sector have been undertaking work that could qualify for R&D tax relief and they should be taking full advantage.’

Cavendish’s dr Benjamin holdsworth

Plan to force insurance cover on private doctors

By Robin Stride

Consultants would be forced to replace discretionary protection with mandatory contractual insurance indemnity cover under controversial proposals sent to Health Secretary Jeremy Hunt by the private hospitals’ trade body. According to the NHS Partners Network (NHSPN), this would ‘ensure that no patient would ever lose out if affected by poor care in the independent hospital sector.’

Its plan surfaced in an 18-page response to Mr Hunt after he told the private hospital sector to get its house in order following shock ratings figures from the Care Quality Commission (CQC). As we reported last month, the watchdog found 41% of hospitals required improvement and 1% were inadequate for safety. 30% required improvement and 3% were inadequate for being well led. But the network’s comments (see box) unsurprisingly brought a strong reaction from the traditional medical defence organisations, while attracting a thumbs-up from newer insurance companies who would stand to benefit.

MDDUS chief executive Chris Kenny warned: ‘We believe that changing the basis of medical negligence cover increases cost and so makes independent providers less attractive as partners to the NHS, without materially improving outcomes for either patients or providers. NHSPN should be careful what they wish for.’

Simon Kayll, chief executive at the Medical Protection Society, responded: ‘Discretion enables a flexible approach which means we are able to anticipate the unexpected, adapt to constant advancements in clinical practice and provide indemnity in a range of unusual and often unforeseen circumstances, going above and

beyond the ordinary scope of protection to defend a member’s interest.’

He said it was ‘extremely rare’ for MPS to decline a request for assistance. ‘The circumstances would have to be exceptional and a decision is only made after extensive, objective deliberation about the best interests of the wider membership.’

MDU boss Dr Christine Tomkins said: ‘It is simply wrong to suggest that insurance will ensure patients will be fully compensated if they were damaged by negligent care in the independent sector.

WhaT ThE nhS PaRTnERS nETWoRk Told jEREMy hunT

‘To continue to ensure that patients have maximum confidence and protection, we call for a regulatory change to ensure that all clinicians are required to have mandatory rather than discretionary insurance.

‘We do not believe that a system of discretionary insurance cover for clinicians can provide the necessary public reassurance that, if something goes wrong in a healthcare setting, that patients will be entitled to compensation no matter what the cause or intent.

‘This is why, as part of our contribution to the Paterson Inquiry, we are working with partners to assess what could be done to establish a comprehensive insurance regime for clinicians that would move away from the existing discretionary nature of the cover available.

‘To help with this, we think that the Government should consult widely on requiring all clinicians to have mandatory insurance in place as part of their licence to practise, alongside taking forward discussions with the medical defence organisations, the insurance market, providers, royal colleges and the GMC to design a workable, comprehensive system of insurance for all clinicians working in England.’

‘The report of an independent review of indemnity conducted for the Department of Health in 2010 concluded: “Making insurance or indemnity a condition of registration will not guarantee that every registered healthcare professional will at all times have adequate and appropriate cover.” That position has not changed.’

Roger Houston, chief executive at Medical Risk Services Limited, said: ‘The lines between private and NHS work are becoming increasingly blurred, creating uncertainty over whether doctors can fall back on Crown Indemnity – and posing a genuine risk, for example, that doctors could be held liable for NHS costs resulting from disputed private work’.

ation Network welcomed his intervention, saying alignment with NHS data standards was long overdue. Mr Hunt had sent an important message to independent providers about the need to not simply engage with PHIN, but to really embrace data transparency as a central part of clinical governance and service improvement.

But Andy Foley, managing director at Bespoke Medical Indemnity, called it ‘an exciting and welcome recommendation’ for commercial insurance.

He argued that discretionary indemnity could potentially render a clinician and patient vulnerable, and it needed scrutiny.

Mr Hunt urged greater transparency from the sector and gave providers two weeks to respond to his criticism. He wrote: ‘Given that the sector employs many NHS consultants who have benefited from NHS training, relies on the NHS as a safety net for emergency care, and holds a number of NHS contracts, a situation where it is potentially letting down patients on safety and quality is unacceptable.’

The Private Healthcare Inform-

NHSPN boss David Hare said independent hospitals had an excellent safety and quality record with the CQC. Seventy per cent of independent hospitals were rated as either good or outstanding, comparing favourably to similar NHS services.

‘But we do acknowledge that further work is needed. We have set out in our correspondence what is being done to improve overall consistency in key areas including patient transfers, clinical governance and clinical liability and have described how individual operators can work much more closely with the CQC in the event that a service is rated inadequate.’

Mdu boss Christine Tomkins

The CQC report painted a poor picture of private hospitals

Roger houston, head of Medical Risk Services ltd

Reassuring words from industry body

The boss of the organisation representing private healthcare providers from this month has assured them their interests will be heavily promoted, even though they are under the wing of an NHS body.

NHS Partners Network chief executive David Hare’s reassuring message came following the announcement last month of two new team member appointments.

He said he looked forward to working with them to ensure the NHS Partners Network was ‘the strongest possible advocate for our members so that the safe, highquality and innovative services delivered by independent healthcare providers can be accessed by as many people as possible’.

The network took on private hospital representation following

the closure of the Association of Independent Healthcare Organisations (AIHO) from 1 June ( Independent Practitioner Today , March 2018).

David Furness has joined the team as director of policy and delivery from his role at NHS Improvement, where he was a senior policy adviser. Disa Young becomes assistant director of regulatory affairs and engagement, having worked as AIHO’s head of external affairs and communications.

Mr Hare said the pair were ‘two fantastic additions’ to his growing team, and their valuable insight and experience would be a real asset as the network expanded its remit to provide ‘a single united voice’ on behalf of the independent healthcare sector.

Growing pathology firm hires commercial chief

Independent histology and cytology laboratories Cellular Pathology Services (CPS) has appointed Scott Hague as commercial director.

The company said the appointment followed several years of exponential growth driven by increasing demand for its pathology services, mainly from private consultants, clinics and hospitals across the UK.

Mr Hague (right) previously ran his own London-based digital marketing agency in the healthcare sector and was also a director of the global healthcare consultancy, Worldwide Healthcare Associates.

He said the healthcare market increasingly offered many new opportunities for growth and his goal was to make CPS the number one private

histopathology and cytopathology lab in the UK.

Co-founder and managing director Dr Joseph El-Jabbour said: ‘Scott will help to provide the strategic direction for CPS, using his expertise and leadership skills in managing all client accounts, together with marketing and new business activities.’

Call for death duty reform

By Charles King

Inheritance tax should be abolished and replaced with a new system attracting greater public support by being fairer to families and harder to avoid, according to a think-tank report.

Inheritance income has doubled over the last 20 years – hitting over £100bn in 2015-16 – and is forecast to double again over the next two decades as Britain’s record levels of wealth is passed on through families.

But, according to the Resolution Foundation, although the increase will benefit many millennials, inheritances will be unable to deal with the big economic challenges facing families or the country:

 For families, that is because the most common age at which the current millennial generation are expected to inherit is 61 – far too late to help with buying a home or bringing up children.

 For the state, inheritance tax

does a poor job of collecting revenue. It accounts for just 77p of every £100 raised nationally, and just 4% of estates are now subject to it.

The foundation says the tax is unfit to deal with wealth in modern Britain because, despite its limited revenue-raising ability, it is regarded as Britain’s least fair tax.

It claims this unpopularity is due in part to it being perceived as a tax on the dead, having a high marginal rate of 40%, and because it is often seen as merely a voluntary tax for the very rich and those who are well-advised.

The think-tank believes the tax should be replaced by a new lifetime receipts tax, with a much lower rate.

It says: ‘Those benefiting from any inheritances would be taxed instead of the deceased’s estate –but only for any inheritances beyond a lifetime allowance.

‘This would have the added ben-

efit of encouraging families to spread their wealth, as each beneficiary would have their own tax allowance.’

The report adds that this new approach would significantly reduce the scope for the very rich to reduce their tax bills by making large gifts well before passing away, something ordinary families whose assets are largely tied up in a house are unable to do.

It says applying an allowance of £125,000 to a lifetime receipts tax, followed by a 20p rate up to £500,000 and 30p after that, would cut the marginal rate of tax on wealth transfers significantly while still raising up to £11bn in 2020-21.

This is compared to the £6bn that the current system is projected to raise.

The foundation’s senior economic analyst Adam Corlett said: ‘Rather than tweak our failed inheritance tax system, it should be scrapped altogether and

replaced with a new lifetime receipts tax.

‘This new system would be fairer to families, harder to avoid and would ensure our tax system keeps up with 21st-century Britain.’

David Redfern, of DSR Tax Claims, said inheritance tax was one of several areas of taxation legislation that needed to be reevaluated to bring it in line with changes in modern living and working.

He said: ‘Not only is the current system greatly disliked by the public, who perceive it as a tax on the dead, it doesn’t actually raise much taxation revenue for the Government.

‘And, as is so often the case, the taxation burden is much easier to avoid for those with the financial resources to take advantage of the various tax reliefs available, pushing that burden on to those less able to shoulder the financial weight.’

Practice strives for non-surgical cures

By Edie Bourne

Sports and non-surgical orthopaedic consultant Dr Ralph Rogers is opening a new private group practice: Rogers Regenerative Medical Group.

Based at 25 Harley Street, it is the culmination of his vision to launch a holistic regenerative clinic.

He told Independent Practitioner Today it would bring together ‘the very best and most dynamic people in their fields’, including sports physicians, osteopaths, radiologists, rehabilitation specialists, dieticians and a human metabolism specialist.

There will be a performance lab and he will offer patients a number of regenerative treatments, including Lipogems, for which he was trained by its inventor Prof Carlos Tremolada in Milan.

After moving from the US in the late 1990s, Dr Rogers had a practice in Birmingham before moving to Harley Street in 2008. He was an original partner of the London Orthopaedic Clinic.

Dr Rogers formed the Sports Injury Clinic at 108 Harley Street, where he still practises, but said the Rogers Regenerative Medical Group would enable him to bring his own style and methodology to the practice. The group will bring non-surgical solutions for orthopaedic complaints.

The practice expects to attract patients from across the self-pay and insurance spectrum. Lipogems treatment costs £3,950 for a knee, and for two knees £4,950.

Dr Rogers said: ‘The Rogers Regenerative Medical Group is the start of what will be a new journey for me. I strongly believe that if

you have a vision you should follow it and if you provide clinical excellence, you will be financially successful.

‘Team members have been very excited by my vision for the future of the group and I am always on the look-out for top physicians who buy into the ethos to join me.

‘I have considerable experience working with elite athletes at the National Basketball Association and Chelsea Football Club, but you don’t have to be an elite athlete to be treated like one, and this is the philosophy the group will follow.

‘Being free from pain is lifeenhancing and I want to make this accessible and cost-effective for a far wider group than ever before … Private practice is challenging; but with self-belief, determination and hard work it’s rewarding in every way.’

Benefits of mobiles in clinics are unexploited

Healthcare organisations are failing to realise the full potential of mobile device usage in patient waiting areas, claims a patient journey management specialist.

Qmatic claims that letting waiting patients book appointments using their smartphone would boost efficiency and cut waits.

In interviews with 600 healthcare IT decision-makers across the world, the firm found mobile devices most commonly used in nurse’s stations (72%) and administrative offices (63%).

They were least used in patient waiting areas (38%).

Qmatic’s boss Vanessa Walmsley said: ‘While it’s great to see that healthcare IT decision-makers are realising the benefits of mobile devices for both staff and patients, many are missing out on additional efficiency gains and increased patient satisfaction through implementing mobile device initiatives for patient waiting areas.’

Managers could greatly improve patients’s experience at outpatient departments and in waiting areas by enabling them to use a mobile device to check in for a pre-booked appointment or select a walk-in service such as phlebotomy and join a virtual queue.

This technology eliminated the friction of patients having to wait in line to see a receptionist, reduced staff pressures and gave patients information about where to go and who to see.

HCA unveils members of ‘quality’ board

HCA Healthcare UK has announced inaugural members of its new advisory board set up to support the hospital group’s agenda around quality care and sector-wide collaboration.

They are:

 Ed Smith, chairman: former chairman of NHS Improvement and deputy chairman of NHS England;

 Prof Sir Bruce Keogh: NHS England’s medical director and professional lead for NHS doctors until the end of 2017;

 Prof Sir Robert Lechler: most recently vice-principal (Health) of King’s College London;

 Prof Dame Shirley Pearce: former vice-chancellor at Loughborough University, where she established

the National Centre for Sport and Exercise Medicine;

 Beverley Aspinall, a consumer behaviour specialist: former managing director of John Lewis.

HCA Healthcare UK chief executive Mike Neeb said: ‘I am delighted to have such experienced and knowledgeable members as part of our advisory board.

‘Our board members’ collective expertise and insights across the healthcare, public and commercial sectors will be a great asset to HCA UK as we continue to focus on delivering the highest-quality patient care, and look ahead to the future development of our network of hospitals and facilities.’

Dr Ralph Rogers

Doctor invents app to solve data issue

By Leslie Berry

Independent practitioners using instant messaging to discuss patients could face fines of up to 4% of their annual turnover following last month’s introduction of the EU’s General Data Protection Regulation (GDPR), a consultant has warned.

The new legislation prohibits the use of services such as iMessage and WhatsApp for sending messages containing nonanonymised information about patients, as these store data on servers outside of the EU, contravening the new rules.

Many practitioners like instant messaging’s convenience, particularly when working across multiple locations, as face-to-face contact can be limited and phone calls can interrupt work.

But entrepreneur Mr Neville Dastur, a consultant vascular and endovascular surgeon in Surrey, said the new data protection rules generally required anyone want-

ing to share someone else’s data to get that person’s explicit consent first.

He told Independent Practitioner Today : ‘There are exemptions to this rule for health professionals who need to talk about or with patients, but to take advantage of these exemptions, the onus is on the practitioner as the data controller to ensure patient information is handled correctly.

‘Practitioners looking to avoid fines find themselves having to become specialists in both data compliance and information technology in order understand the myriad of legislative and security requirements.’

With a strong background in healthcare IT, he saw the advantages of using instant messaging in his own private practice, but also spotted the possible risks of data breach once the new legislation came in.

So he set about designing a messaging service to give healthcare professionals the convenience of

Call for plan to solve nursing shortages

Private hospital groups have welcomed a Royal College of Nursing report calling for a long-term workforce strategy to address nursing shortages across the whole of the health and care system.

David Hare, chief executive of their trade body the NHS Partners Network, said: ‘Independent healthcare providers currently employ over 60,000 nurses, but, like their counterparts in the NHS, are experiencing high vacancy rates given the recent drop in applications from nurses of all levels of experience, which is placing significant pressure on the existing workforce.’

Independent hospitals are looking forward to seeing the contents of a Health Education England ten-year workforce plan.

Mr Hare said they wanted a system-wide approach to workforce planning which reflected the diversity of health and care provision and the important role played by the independent sector in delivering high-quality patient care.

The BMA warned that nurse shortages were having a ‘devastating impact’ on patient care in the NHS. It blamed the recruitment and retention crisis on ‘chronic underfunding’.

the apps they found so useful, but with the built-in security and compliance allowing them to communicate freely without having to anonymise patient information.

Working with James Flint, a former technology journalist specialised in building data-compliant media platforms, they launched Hospify in 2017 ‘to tackle GDPR head-on’.

Mr Dastur said: ‘Practitioners simply want to send messages without the worry of what is and is not compliant.

‘Messages sent on Hospify are not end-to-end encrypted and are deleted from Hospify’s exclusively EU-based internet servers after delivery, ensuring that the only copies are stored in the sender and receiver’s phone or tablet. The app itself is protected with a PIN code, and even messages stored within the app are deleted after 30 days.

‘This helps ensure that any sensitive patient data transmitted using the app is sent, stored and

‘In-spired’ opening

Mr Neville Dastur with his app which allows messaging to comply with the stricter EU data regulation

deleted in line with GDPR legislation, and helps ensure that the practitioner using the app stays compliant with both GDPR and UK data protection laws.’

Hospify is used by NHS staff and trusts, private health care providers and the nursing and managers’ unions UNISON and MiP in various sites to give healthcare staff free access to secure and compliant healthcare instant messaging. Hospify has ISO 27001 and NHS IG Toolkit accreditation.

The Hospify app is available to download and use for free from the Apple and Android app stores.

Compiled by Philip Housden Kingston’s Coombe wing PPU

There is a new twist to my story ( in February) about Kingston Hospital ending its partnership with BMI to run its 23-bed PPU.

Although the trust reported that One Healthcare were preferred bidders to take over the PPU and then build a new hospital on campus, it is understood that this deal has run aground.

Now the trust is seeking to procure a new partner to manage the PPU from April 2019 on a likely four-year contract.

On offer is a fixed management fee plus a success payment based on profit growth in return for providing leadership, clinical operational management, and the back office team and systems.

Former England rugby player and recently qualified doctor tom Rees opened a new MRI unit at spire st Anthony’s Hospital, Cheam, surrey.

Beware tricksters trying to impersonate taxman

By Edie Bourne

Businesses and individuals are being urged by HM Revenue and Customs (HMRC) to stay vigilant in the fight against fraudsters, who are using email and text messages to scam people out of their savings.

The tax authority is currently processing tax refunds after the end of the 2017-18 tax year. But criminals are taking advantage of this by sending out scam emails and text messages to trick people into thinking they have received a tax rebate so that they hand over their account and personal details.

Treasury Minister Mel Stride said: ‘HMRC only informs you about tax refunds through the post or through your pay via your employer. All emails, text messages, or voicemail messages saying you have a tax refund are a scam.

‘Do not click on any links in

HOw tO AVOID A tAx REBAtE sCAM

Recognise the signs – Genuine organisations like banks and HMRC will never contact you out of the blue to ask for your PIN, password or bank details.

Stay safe – Don’t give out private information, reply to text messages, download attachments or click on links in emails you weren’t expecting.

Take action – Forward suspicious emails claiming to be from HMRC to phishing@hmrc.gsi.gov.uk and texts to 60599, or contact Action Fraud on 0300 123 2040 to report any suspicious calls or use their online fraud reporting tool.

Check GOV.UK for information on how to avoid and report scams and recognise genuine HMRC contact.

If you think you have received an HMRC-related phishing/bogus email or text message, you can check it against the examples shown in this guide.

these messages and forward them to HMRC’s phishing email address and phone number.

‘We know that criminals will try and use events like the end of the financial year, the self-assessment deadline and the issuing of tax refunds to target the public and

attempt to get them to reveal their personal data. It is important to be alert to the danger.’

Many of these fraudulent emails and texts include links which take the user to dubious websites where their information can be stolen.

These sites are a focus of HMRC’s efforts to tackle fraud. In March 2018 it requested 2,672 phishing websites be taken down and received 84,549 phishing reports.

This kind of phishing is expected to continue in the coming months as genuine tax refunds are issued.

Income tax for 6 April 2017 to 5 April 2018 will be calculated over the coming months and any doctor owed a genuine tax rebate will receive a tax calculation letter by post between June and October.

If you have not paid the right amount at the end of the tax year, HMRC will post you a tax calculation. This can be a P800 or a Simple Assessment letter.

If you have paid too much tax, the letter will explain how you can get your refund paid to you. If you have not paid enough tax, the letter will tell you how much you owe and how you can pay.

‘Lifestyle GP’ to boost preventative care

OneMedicalGroup, a Yorkshirebased health provider with ten sites across the UK, has appointed its first lifestyle GP – TV presenter Dr Helen Lawal.

She will lead its health and wellness offering across the group, also known for its OneWellness brand.

Dr Lawal will help people take a holistic approach to their health and wellness needs, in line with the growing trend and emphasis towards preventative and lifestyle medicine.

She holds degrees in both sport and exercise science and medicine.

She said: ‘We are beginning to see a shift in the roles of GPs and other clinicians towards preventative medicine and the promotion of lifestyle changes, including

addressing nutrition and exercise, as an effective and low-risk approach to preventing disease and managing and reversing chronic lifestyle-related disease such as diabetes.

‘The new Health and Body Transformation programme I’ll be offering supports people to prioritise their own health and wellbeing. It enables them to reshape their daily lives by giving them the tools they need to create healthy new habits and routines to ultimately improve their quality of life, prevent disease and manage any existing health problems.’

Dr Lawal said by being there every step of the way to provide accountability and support with a tailored programme wrapped

Dr Helen Lawal, appointed to boost preventative care at OneMedicalGroup

around each client’s needs, she and OneWellness staff would help members stay motivated and see improvements in their health and sense of wellbeing.

OneMedicalGroup chief execu-

tive Rachel Beverley-Stevenson said consultations with Dr Lawal would be available across all OneMedicalGroup sites and she would also provide online video appointments nationally.

New guidelines to help revalidation

By Olive Carterton

Doctors have been issued with new GMC guidance to help them collate information necessary for appraisals and revalidation.

They are expected to collect six types of supporting information:

1. Continuing professional development;

2. Quality improvement activity;

3. Significant events;

4. Feedback from colleagues;

5. Feedback from patients;

6. Complaints and compliments.

Some doctors have found the requirements remain unclear and Sir Keith Pearson’s review last year, Taking Revalidation Forward, led to him recommending the GMC should update its guidance on supporting information.

It was asked to clarify what is mandatory for appraisal and revalidation, and how that differs from additional requirements of employers, royal colleges or faculties.

The GMC’s updated guidance, available on its website, now:

 Provides information on the balance between quality and quantity of supporting information that a doctor must collect, but explains that the GMC does not set a minimum or maximum amount;

 Reinforces the importance of doctors who have multiple roles gathering information that covers the whole of their practice;

 Emphasises that appraisals and revalidation are not ‘pass or fail’ exercises, but should be developmental;

 Provides more information on collecting feedback from colleagues.

Una Lane, the GMC director of registration and revalidation, said the guidance had been updated following engagement with a range of doctors, appraisers and healthcare organisations.

She said: ‘Most doctors are now collecting the supporting information that revalidation requires, but, for many, the processes for doing so are not as simple and straightforward as they could be.

‘Employers have a major role to play to address this and too often there remains confusion between the GMC’s requirements and

those of employers or royal colleges. Our updated guidance will help doctors by making our requirements clearer, with a focus on quality rather than quantity.’

As well as updated content, the GMC’s guidance on supporting information has also been redesigned to make it easier and quicker for doctors to find the information they need.

It has also published new guidance on revalidation for Responsible Officers – doctors who make revalidation recommendations for colleagues – and new principles on information­sharing for when doctors move between designated bodies or work in multiple settings.

InquIry TO BOOST wOrkInG COnDITIOnS

A GMC initiative aims to tackle the causes of poor well-being experienced by many doctors.

It will analyse causes of workplace stress, the support currently available and how workplace stress and mental health conditions among doctors compare with other professions both within and outside healthcare.

The GMC said it would use the findings of the independent report to work with organisations to improve working conditions and support for doctors and medical students.

Campaign to stop staff being underpaid

A new campaign from the taxman is urging staff who think they are underpaid to check their pay and call the employment service ACAS for free and confidential advice.

Business minister Andrew Griffiths warned employers pay ­

ing illegal rates that they would be forced to pay back every penny and could be hit with fines of up to 200% of wages owed.

From 1 April 2018, the Government’s national living wage rate for those aged 25 and over

Guidance to aid doctors reflect on their work

New guidance for doctors on reflective practice is being produced jointly by the GMC, the Academy of Medical Royal Colleges, the Conference of Postgraduate Medical Deans and the Medical Schools Council.

Dr Colin Melville, GMC director of education and standards, said: ‘We know a lot of doctors recognise the importance of being reflective practitioners but are concerned about how their reflective notes might be used against them.

‘The new guidance will address those concerns. Working in collaboration with colleagues from key medical education organisations will go a long way to ensuring we have guidance that will be a real and practical help to doctors.’

Prof Sheona MacLeod, chairman of the Conference of Postgraduate Medical Deans, said: ‘Reflecting on practice is a key professional skill which helps individuals, teams and organisations learn and improve patient care.

‘The new guidance will help clarify how doctors can safely demonstrate their professional approach as reflective practitioners, focusing on the outcomes of reflective practice rather than on specific details.’

The guidance is due for autumn publication.

increased by 33p to £7.83 per hour. The national minimum wage rose for 21­24 year­olds by 33p to £7.38 per hour; 18­20 yearolds by 30p to £5.90 per hour and 16­17 year­olds increased by 15p to £4.20 per hour.

Prof Sheona MacLeod, chairman of the Conference of Postgraduate Medical Deans

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Visit www.sanofipasteur-portal.co.uk to explore our range of services and see how they could help you with your surgery’s vaccine management.

Good ideas for boosting income

The con T inued push-back by insurers on consultants’ fees is becoming more serious and affecting their income adversely.

And this is especially the case for longer-serving consultants because, traditionally, they commanded higher fees.

Well, it is always worth looking at other revenue streams.

Share of other services increasingly, more consultants are taking a revenue share of other services, such as X-rays, imaging and plaster-cast clinics.

Another stream are wellness and fitness offerings including nutrition, massage, Pilates and yoga for medical purposes. Think about this if you have unused space in your practice premises.

Retail-style services

Another trend emerging is retailstyle services; for example, MR i scans and wound treatment, operating from retail premises.

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c ertainly, in recent times, patients are more willing to look at this type of offering and it may be worth consultants getting together to set up an offshoot to their normal practice in this way.

Technology is allowing certain types of conditions to be treated at home with patients being monitored wirelessly. even chemotherapy, in some cases, could be administered from a patient’s home.

The question here is can consultants themselves benefit financially from procedures that were traditionally hospital or practicebased but which can now/shortly be carried out either in a retail environment or in the patient’s home? it is always worth thinking outside the box.

Making the most of tax breaks

Thinking outside the box could bring you an increased income, says Susan Hutter (right)

Remember that, for consultants trading as companies, there are valuable tax breaks for expendi - ture on qualifying research and development. depending on the nature of the expenditure, tax relief can be up to 230% of the expenditure.

For example, for fully qualifying research and development ex penditure of £100,000, a total of £230,000 would be set off against income in the company’s accounts and tax relief at 19% would be obtained. in this example, the extra tax saving would be just under £25,000.

There are also tax breaks for most consultants willing to invest in start-ups.

This is by way of the enterprise investment Scheme (eiS) and Seed eiS (SeiS) and eiS relief where the

investor’s shareholding is less than 30% in the qualifying startup.

d epending on the stage the business has arrived at when you invest, the tax relief can be 50% of the investment, although this is only for the first £150,000 raised, it is 30% thereafter.

There are also valuable capital gains tax breaks to SeiS/eiS investors who hold their shares for three years or more

As always, it is important to take professional advice before proceeding. 

Susan Hutter is a partner at Blick Rothenberg and part of the team that advises medical practitioners

The bespoke pathology service for your practice

WHEN A DOCTOR needs confirmation of a diagnosis or a measure of the progress of a treatment or condition, he or she needs to be 100% certain that the sample they have sent off will be assessed and reported on accurately and quickly.

Every doctor needs that certainty, that trust, every single time they send a sample to the pathology lab.

Most patients arrive at the clinic or consulting room feeling anxious, unwell and needing advice, reassurance and often, some measure of certainty. The patient, frequently unsure and slightly disoriented, particularly if it is the first time they have been referred to a specialist, puts his or her trust in their doctor. So the faster the test is reported, the earlier the treatment can begin.

Because of our experience over the years, when we set up Cellular Pathology Services (CPS) we wanted to provide a higher level of

service, a more accessible, agile, and more direct service, where for example, we could offer every doctor personal contact with the consultant pathologist whenever it was needed. We wanted to become an extension of their practice.

It is why we prefer to work as a close partner and collaborator, helping our clients to provide a world class standard of care for every patient. It’s part of our culture at CPS.

We are here for our clients whenever required; we are there at MDTs, we are available on the phone or in person. We are always available.

Working with practice or nurse managers, we strive to take away any process hassles to provide a seamless and timely service. Our own team of drivers get to know the special needs of each customer and make sure we receive samples without delay. At every level, we try constantly to make doing business with us very easy!

Every member of our team is focused on the needs of our clients; everyone is passionate about their work. Every member of the team is at the top of their game and the esprit of our team is palpable. We like to think this is unique in our sector!

As a result, our customers tell us they enjoy more than just a cold, standard business relationship with CPS.

And that’s how we build our reputation. By getting to know each client and adapting our services to match its particular requirements and ensuring access to our team, whenever that’s required.

Perhaps it is why much of our new business comes by recommendation and why we continue to grow to meet customer demand.

So, if you are looking for a pathology service that can be structured specifically for your practice, then call me, Scott Hague on 07741 855 550.

Histopathology, Diagnostic Cytology, Gynaecologic Cytology, Mohs Surgery, Frozen Section are just some of our services.

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billing qUiz

Working

How is the business side of your practice performing? Try this quiz, compiled by Findlay Fyfe (below), to find out

How often do you raise invoices?

A Daily

B Weekly

C Monthly

D When I get time

What system do you raise your invoices on?

A A practice management system

B Word

C Excel

D Any other method

Where do you store the sent invoices?

A A practice management system

B Word

C Excel

D Any other method

Can you send electronic invoices to the insurers?

A Yes, to all the insurers that accept electronic invoices

B Yes, to most of them

C Yes, but only to one or two

D No

How often do you check the fee schedule with each insurer?

A Monthly

B Quarterly

C When I get the time

D Never

How often do you check for changes to Clinical Coding & Schedule Development group (CCSD) coding?

A Monthly

B Quarterly

C When I get the time

D Never

When you receive a payment from an insurer, when do you reconcile the payment?

A That day

B That week

C That month

D When I get time

for free?

How often will you chase an insurer if they have not paid an invoice?

A That day

B That week

C That month

D When I get time

How often do you chase self-pay patients for outstanding invoices?

A That day

B That week

C That month

D When I get time

How do you chase outstanding self-pay invoices?

A Phone several times and send up to three chase letters

B Phone once and send three chase letters

C Phone several times’

D Phone once

Findlay Fyfe is the managing director of Medical Billing and Collection

HOW DID YOU DO?

Go through your answers and mark yourself as follows:

A 3 points

B 2 points

C 1 point

D 0 points

IF your tAlly Is:

30 PoINts

You are a star biller and a shining example to the profession. You have everything under control.

20-29 PoINts

Very good, but there is some room for improvement. Focus on the areas where you scored badly to identify how to improve.

5-19 PoINts

Very poor. I suggest a full review of your billing procedure straight away, as it is likely that you are both losing money and building debt.

0-5 PoINts

Oh no! You are clearly working PRO BONO! It is likely that it is costing you to be in private practice. Seek help.

What’s after Brexit?

How will Brexit affect private healthcare? Jane Braithwaite examines the areas that might catch out independent practitioners

There has been plenty of doom and gloom about Brexit and how it might affect healthcare, but it is entirely possible that private healthcare may see some benefits from the increased competition.

While the impact on the N hs has been keenly analysed since the referendum result was first announced, there hasn’t been as much dissection of how the private sector might fare. Of course, factors which affect the N hs could also have an impact on private healthcare.

Many commentators have highlighted the risks that Brexit poses to the UK economy, but it is somewhat impossible to predict at this point what repercussions of any Brexit-related economic downturn might have on healthcare.

By contrast, it is significantly easier to assess the following key areas of healthcare which are likely to see significant changes: the

workforce, health tourism and the regulation of drugs and devices.

There is so much concern over Brexit’s impact on healthcare that a number of organisations banded together to issue a plea for the UK and eU governments to prioritise patients. This article highlights some of the issues mentioned in the policy statement that are likely to affect the private sector.

How Brexit might affect:

The Workforce recruitment and retention have been flagged as significant problems for the Nhs, but the private healthcare workforce is much more variable.

although the Nhs can exactly pinpoint how many of their staff were born overseas, similar statistics do not exist for staff working privately in the UK. anecdotally, though, many may agree that London’s private hospitals and clinics feature international teams.

e ven conservative estimates mean that there could well be issues for private practices keeping and attracting medical and administrative staff. There were chronic shortages of doctors across all specialties even before the referendum and applications for medical school and the foundation programme continue to drop. around 10% of Nhs doctors are eU nationals and the dramatic fall in the number of e U nurses registering to work in the UK is additionally cause for concern –applications dropped by 87% in 2017.

The private sector needs to become an even more attractive prospect for trained and experienced staff. This might mean turning more to external recruiters and adopting more modern recruitment methods. Could your training and education plan do with a refresh to benefit current and prospective staff?

Finally, providers need to consider succession planning – if they haven’t already – to help avoid a recruitment crisis.

How Brexit might affect:

Health tourism

after a strong period of growth in 2013-15, revenues from overseas patients slowed somewhat in 2016-17.

spire healthcare cited a reduction in health tourism as a factor in the decision to shelve plans for a private hospital in London.

But if the pound weakens further, London and other major cities could become more attractive to overseas visitors. It is already a popular destination for patients seeking world-class care and specialties not available elsewhere.

The Middle east market is a particularly important one for the h arley s treet Medical a rea and Birmingham’s edgbaston Medical Quarter, who have exhibited at the a rab h ealth e xhibition two years running.

But it is not just Middle eastern patients who may need to access private healthcare in coming years. If Brexit means that eU citizens can no longer receive N hs treatment, might they turn to private medical insurance instead?

Citizens of the european economic area (eea) living in the UK may have little choice but to take out private medical insurance as individuals, or there may be a rise in corporate insurance for e U companies who stay in the UK.

How Brexit might affect: Regulation of drugs and devices

When Brexit finally takes effect, the UK’s influence in the approval and regulation of drugs may decline significantly. The e uro -

The private sector needs to become an even more attractive prospect for trained and experienced staff. This might mean turning more to external recruiters and adopting more modern recruitment methods

pean Medicines agency (eMa) is currently based in London and the UK has considerable influence – 20% of the eMa’s activity comes from the UK.

The e M a will relocate to amsterdam after Brexit and some commentators believe that the shift may mean the UK will also lose its influence in getting new drugs and devices to market. This could mean that medicines and innovative devices could reach the UK market later than they do now, which will affect private patients just as much as those in the Nhs another regulation issue which has had a great deal of attention is the possible disruption to cancer treatments. If the UK is no longer a part of e uratom, which regulates the european nuclear industry, it needs to find another way to access radioisotopes that are used for radiotherapy among other treatments.

This could mean significant

delays for treatment, and patients will naturally be affected.

London is currently a world leader for the treatment of cancer, with many specialist private clinics in harley street and elsewhere. If the UK Government does not resolve these issues in time, patients may start to look to other countries for medical care and private providers could feel the impact.

conclusions

Private hospitals, practitioners and clinics in London are less likely to be affected by Brexit as the capital is well-established as an international centre of excellence for healthcare.

Outside of London, the longterm economic impact of Brexit may be what makes the most difference to the private medical insurance market. a long with other industries, private healthcare is affected by the continuing uncertainty of the Brexit negotiations. 

Top Tips To prepare for BrexiT

staff check

How many of your staff are from the eU? How can you help or advise them in coming months? euratom matters

if you rely upon radioisotopes to provide treatments, keep a keen eye on news relating to euratom. focus on unique selling points

staff recruitment will become even more critical in years to come. Why should staff work for you – what makes you unique? spell out the benefits.

Who pays?

The self-pay market is strongly rumoured to grow as individuals tire of lengthy NHs waiting lists. Do your procedures make it easy to take on more self-pay patients? plan ahead

Brexit may mean facing up to bigger bills for drugs, devices and other consumables. Have you given any thought to how larger devices such as scanners can be financed if costs rise?

Jane Braithwaite (right) is managing director of Designated Medical, which offers business services for private consultants including medical secretary support, book-keeping and digital marketing

Free legal advice for independent practitioner Today readers

independent practitioner Today has joined forces with leading healthcare lawyers Hempsons to offer readers a free legal advice service.

We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.

Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.

call Hempsons on 020 7839 0278 between 9am and 5pm Monday to Friday for your ten minutes’ of free legal advice.

Advice is available on:

 Business structures (including partnerships)

 commercial contracts

 Disputes and litigation

 HR/employment

 premises

 Regulatory requirements and investigations

Dear Reader,

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If the GMC calls. . .

There is probably nothing anyone can do to entirely eliminate the risk of a GMC referral, says Tania Francis (below). Sometimes, it is down to just plain bad luck. It is certainly often nothing to do with your abilities as a doctor, and that’s important to remember if you are unlucky enough to receive the dreaded GMC letter

It’s Important to bear in mind that not all complaints to the G m C go anywhere. m any are weeded out by the G m C at an early stage, sometimes without you even knowing anything about them. others are investigated and then closed. You may be asked for your comments on a complaint or allegation.

If that happens – take advice from your medical defence organisation or insurer. You may be advised to say nothing at all at the very earliest stages.

this could be because it’s better to wait until you know more about the allegations and the evidence there is to support them. a t this early stage, you will not yet have access to all the relevant documentation –and any other evidence – and you should not rely on your memory.

By making comments early, you may say something that is inaccurate or unhelpful. that’s not always the case, of course. If you have a straightforward defence –‘You’ve got the wrong doctor. It was the other Dr Bloggs’ – then that’s certainly worth saying.

It’s also important to know what sort of issues the GmC will investigate. the worstcase scenario if you are referred to the GmC is that the complaint is eventually referred

to a hearing before a medical practitioners tribunal (mpt).

that tribunal will have to decide whether the facts are proved and, if they are, whether they amount to one of the statutory grounds for impairment.

those grounds are misconduct, deficient professional performance, a criminal conviction or caution, adverse physical or mental health, or an adverse decision by another UK regulatory body.

If one of those grounds is made out, the GmC will need to decide whether it amounts to current impairment of fitness to practise – taking into account factors such as remediation, insight and personal mitigation.

When thinking about how to minimise the risk of a G m C referral, it is therefore instructive to look at the statutory grounds and also to look at the types of cases which fall within the various categories.

health

poor physical or mental health can lead to a GmC referral. Your health is important. If you become unwell, put yourself in the hands of a Gp or specialist.

Don’t ignore your health, don’t try to deal with ill-health by yourself. Certainly don’t

prescribe for yourself (see further below).

mental ill-health can be particularly difficult, and difficulties with drug and alcohol addiction are common. there are a number of support groups for doctors in this sort of difficulty – call them.

a nd most importantly, don’t work if you are not fit to work, and keep your workload to a manageable level.

that may seem like a ridiculous thing to say if you are overworked, and in a department with staff shortages and rota gaps.

However, if you make your employer/medical personnel/occupational health department aware that you are unwell, they will have an obligation to look after you. If they don’t know, they can’t do anything to help.

I realise this is a very difficult step to take, and that you will be afraid of harming your career by going down this route, and possi-

bly prompting a GmC referral or other action against you by selfdeclaring your ill-health. those risks are real, but it is far, far worse for your ill-health to be reported by someone else because something has gone wrong.

criminal convictions and cautions

I will not go into details about these in this article, but you should be aware that you have a duty to report convictions and cautions to the GmC.

If you don’t, someone else is likely to – either the police or someone involved in the case, or the G m C sometimes finds out from the press.

You must also inform the GmC if you are charged with a criminal offence. You should be particularly wary of cautions – these are sometimes offered by police officers on the promise that a caution is an easy way out, will avoid a

criminal trial and that will be the end of the matter.

that is not necessarily the case. You will need to report the caution to the G m C – and if you don’t, someone else might – and you may then face a GmC investigation.

It may not go to a hearing, depending on how serious the offence was, but you may have to go through a stressful investigation.

If you are offered a caution, take advice from lawyers with experience of both GmC and criminal matters, so that you can properly balance the risk of a more serious criminal record and a GmC investigation.

deficient professional performance this needs little explanation. You must keep up to date, obtain feedback from patients and colleagues, audit your practice, and work

within your scope of competence. Don’t be tempted into carrying out procedures which are not part of your usual practice without adequate further training. Be wary of carrying out procedures where the number you are doing is low – think about whether the patient would be better off elsewhere.

that is particularly important in private practice, where numbers may be lower and where you risk being perceived as motivated by financial gain rather than the patient’s best interests.

Misconduct

t his is a broad category which includes both clinical and nonclinical issues. It’s important to remember that it can, if sufficiently serious, include misconduct in your personal life as well as your professional life.

Behaviour that you may rightly feel has nothing at all to do with

your job or your profession as a doctor may still attract the attention of the GmC.

Examples of misconduct include isolated clinical incidents which are particularly serious: fraud, sexually motivated examinations, prescribing for yourself or your friends/family, and working without insurance.

If, despite your best efforts, you receive notification of a complaint to the GmC – don’t panic. Don’t ignore it. take advice early. most situations can be handled effectively and although the process of going through a G m C investigation is undoubtedly stressful, in most cases there is a way through, and the earlier you start, the better. 

How To proTecT yourselF From an allegaTion oF misconducT

 Keep full, accurate and contemporaneous clinical records. record the process of taking informed consent and make a note of any documentation you have provided the patient.

 work in a team. consult with colleagues and the wider multidisciplinary team. This will not only help prevent errors but also help you to defend your clinical decision-making, should the worse happen.

 use a chaperone. chaperones are there to protect you as well as the patient.

 be aware of professional boundaries with patients and colleagues.

 be careful in any financial dealings, such as billing patients and insurance companies.

 don’t see private patients during nHs contracted time – you are putting yourself at risk of an allegation of fraud. if you consider that you make up the time by doing nHs work in the evenings or at other times, make sure that this is understood and agreed in writing.

 don’t self-prescribe and don’t prescribe for your friends and family – the gmc’s guidance is that this should be avoided wherever possible. if you have to do so, be prepared to justify your decision. make a clear record of what you have done, and let the patient’s gp know – unless the patient objects.

 be a good communicator. it’s hard to emphasise enough the importance of good communication with patients and colleagues.

 be open and honest and apologise if something goes wrong.

 make sure that you have appropriate insurance in place.

 be careful when using social media. don’t post anything related to patients, and don’t post anything you wouldn’t want the gmc to see.

 be a good colleague and allow your colleagues to support you. asking for help can prevent a situation escalating. being a supportive colleague and accepting support from colleagues can prevent errors, systemic and personal. if something goes wrong in a cohesive and supportive department, there is a greater chance of the issue being dealt with locally rather than referred to the gmc. if you are referred to the gmc, testimonial references from colleagues will stand you in good stead.

Tania Francis is a solicitor and partner at specialist healthcare law firm Hempsons. She is also a qualified doctor, who has relinquished her licence to practise More and more consultants are using Medical Management Services for their medical billing.

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Now we are

Independent Practitioner Today has been your eyes and ears for ten years now, bringing you news, advice, and opinion in the fast-changing world of private practice.

Here we look back at some of the most memorable front pages – and on pages 24 to 36 leading lights in the sector tell us how they expect your world to change in the decade to come

➽ Those were the days – they wouldn’t allow it now. £33k for bringing business to your hospital – February 2009

Chartered Accountants, Tax & Business Advisers specialising in the Healthcare Sector

• Tax structures for Hospital Consultants

➽ Tougher Care Quality Commission inspections on the way: ‘yet another erosion of consultants’ autonomy’ – February 2015 ➽

➽ And now it’s happening…consultants’ prices and performance to be shown on the web – May 2015

➽ Accountants fear private doctors in London will feel the financial pain from Brexit – July-August 2016

➽ we warn that rising indemnity costs could force more specialists out of private practice – April 2016

➽ N h S England proposals to force consultants to reveal private earnings were dropped after this story – October 2016

➽ A change in the ‘discount rate’ sends rocketing defence fees even further into space – March 2017

➽ keen interest reported in new private hospitals’ salaried service plans for consultants – November 2017

➽ Too many barriers preventing patients from easily accessing consultants and treatment information – July/August 2017

➽ we celebrate our 100th issue in April with 100 private practice tips from the experts compiled from every issue – free to view at www.independent-practitionertoday.co.uk.

 We will be bringing you a more detailed look back over the last decade in future issues

looking inTo ThE cRysTAl bAll

The future of

To celebrate Independent Practitioner

Today’s tenth anniversary, we have asked some of the most knowledgeable and influential people in private healthcare what they think the sector will look like in ten years’ time

practice

private practice

Ray stanbridge, director, Stanbridge associates, accountancy, finance and tax advisory medical specialists

Independent Practitioner Today has observed significant changes over the past ten years:

 Ever-changing medical technology;

 Pressure from insurers to reclaim fees from consultants;

 New methods of healthcare delivery;

 The impact of the Competition and Markets Authority (CMA) investigation report;

 The increasing demand for data on quality and financial outcomes.

In ten years’ time, there will be fewer beds and overnight stays. All hospitals will be embracing day case treatment referrals.

Insurers will cease to register consultants as individuals and will deal with properly established and regulated groups.

Those who do not want to join with groups will work through locum agencies or become employed by hospitals.

Positive and consistent clinical outcomes will be reflected by additional pay.

Those who are not up to standard will have their fees further reduced.

New hospitals and clinic groups will emerge around the country and some existing ones will be under extreme pressure or be put out of business. These new hospitals will tend to be located where people live.

The NHS will continue but will offer more and more of its noncore business to the private sector.

Who knows, we may yet find a scenario of co-pay or tax relief given on medical insurance premiums to release pressure on the NHS.

The biggest dilemma will be how to insure cancer patients where, for many, their conditions will be of a chronic nature rather than a critical condition. Trouble to come here.

Consultants in private practice will do well – the market is still growing, particularly for self-pay. The prospect for those wanting to engage seriously in private practice is steady, but being an employee is the easier attraction and offer for many.

The days of the great and the good massive practices will probably be gone in ten years’ time.

Almost certainly, my comments will underestimate the changes that will in fact happen.

bertie leigh, consultant solicitor, Hempsons

The future is also a foreign country and we see it through a glass darkly. There are clear pointers to an aging population and increased dependency ratio putting a strain on the NHS and private insurers way beyond any likely funding improvement.

Doctors will routinely access more lifestyle data to anticipate disease development. Patients who fail to manage risk factors like smoking, alcohol and obesity may be refused care by both the NHS and private insurers, leading to more self-paying.

Steps to control the costs of clinical negligence claims will include an end to the funding of care at home and shorter times for claims, but not before the indemnifiers have retrenched further, wiping out far more high-risk areas of medicine.

Private practices will have to change radically and the following trends will accelerate:

☛ More controlled corporate team-led care plans, looking more like the NHS;

☛ More consolidation with private doctors increasingly contracted to corporate hospitals in a bid to reduce the cost of delivering care;

☛ More interventionist control from regulators like the GMC, Care Quality Commission and the Competition and Markets Authority (CMA);

☛ More doctors will commit to ➱ p28

contracts with shares in the organisation in a bid to control the care they deliver;

☛ More online clinics will provide slicker ways to provide care and increase the demand for protected backwaters for the affluent elderly and IT illiterate;

☛ Private consultants and hospitals will need to market themselves to the new web platform providers and the doctors they engage to protect their referral streams;

☛ Harley Street will be challenged by less expensive more local locations;

☛ A far higher degree of patient service as patients dictate more of the terms than the consultants. More accessibility by phone and text will be the norm;

☛ Doctors will be expected to provide more comparable data about previous outcomes and so must do more auditing of their results;

☛ Patients will demand far more information about alternatives in advance and a much more candid assessment of the results afterwards.

keith Pollard, executive chairman, LaingBuisson international Ltd

Picture the age of virtual private healthcare. It’s 12 months since James Brown from Kent had his left knee replaced. Now he has problems with his right.

Since Boris Johnson came to power, NHS waiting lists have ballooned; James faces a two-year wait for his operation and dropped out of his insurance scheme due to the rising cost some years back.

From his handheld device, he video-calls the Amazon Primary Care service that has replaced his local GP and chats to Alexa, his Amazon Health Adviser about his recurring knee problem.

Alexa accesses James’s secure online patient record during the call and reviews his history, recent MRI scan, current fitness levels –tracked via his handheld device and sports club membership.

The app sends James a list of ‘approved’ hospitals with a comparison of hospital and surgeon performance, appointment availability and indicative pricing.

Three of the hospitals are in the UK, two are in Europe.

James submits a ‘get a quote’ request to hospitals in London, Manchester and Croatia to enable them to place a bid for his surgery. The London hospital where he had his left knee replaced videocalls him back immediately, with a ‘second knee special’ price, if he can confirm and book within 24 hours.

The Manchester hospital offers him a video consultation with a leading specialist the following day, and a chauffeur car service pre- and post-op. The hospital in Croatia submits the lowest bid and includes flights, accommodation and a week’s post-op rehabilitation in a spa in their package price.

James likes the new world of private healthcare. He likes patient choice. His wife says: ‘Let’s go to Croatia’.

sue smith, chief executive, independent doctors Federation (idF) Like the development of the universe, the changes in our social fabric, the delivery of all healthcare and the relevance and standing of the delivery of independent healthcare will undoubtedly change.

Of course, ten years is no more than a second in time, but the rate of change is accelerating so quickly that there are some changes in the independent healthcare sector that are predictable and others which may currently feel remote.

Having just had the privilege of being at an IDF seminar listening to Prof Shafi Ahmed, who is a futurist and innovator and who embraces technology, we must be prepared for such advanced technological change that now seems incomprehensible.

The challenges for independent healthcare are not isolated and must be looked at in context of what’s happening in the wider world, particularly with the public sector, with the NHS and the pressures that come to us internationally and politically that affect what is happening on a day-today basis.

The doctor or healthcare professional who chooses to undertake some or all their practice in the

Since Boris Johnson came to power, NHS waiting lists have ballooned; James faces a twoyear wait for his operation and dropped out of his insurance scheme due to the rising cost

wealth of information that is available, the personal touch will remain the holy grail for many patients, and this is particularly the case with the GP-patient relationship.

With these changes come a new set of options and predominantly we hear of the employed doctor model that purports to offer all the freedoms of independent practice but without the selfemployment hassles.

independent sector will increasingly have to embrace the wider ramifications of running a business in an increasingly regulatory environment.

This can be a challenge to devote the time and energy to create an optimum setting that enables the doctor to provide the very best of clinical care that must be delivered.

Accountability will continue to have additional benchmarks set by regulators that can determine the success of a practice and its reputation, indeed its viability.

I unashamedly must promote the IDF in this context and highlight the value and importance of belonging to a network that will support and guide the doctor.

Keeping abreast of change inside the clinical area is difficult enough and to ensure the same attention is given to all other management and regulatory issues only compounds the energy and commitment required.

Additionally, independent practitioners will need to speak with one voice and exert their influence and value within the overall healthcare market.

The existing trend to form medical chambers and groups will continue and its relevance for governance and support can’t be understated. Private medical insurers will look to this model of care and a lone practitioner will be an anachronism.

The impact of digital health models has embraced the knowledge of the patient, who is increasingly curious and makes informed decisions. Outcome measures, performance statistics and customer service are increasingly greater determinants of where a patient will go than just a ‘name’.

The doctor-patient relationship is changing and despite the

New provider entrants to our market promote this model that works quite successfully in other European or American markets. It won’t be right for everyone, but undoubtedly it will appeal to some.

This will cause some fragmentation in the sector and doctors should be mindful not to swap one set of bureaucratic shackles for another. But these models of care are a welcome challenge to the status quo and force us all to examine how care is delivered for the best outcomes for patients and an appropriate environment in which to provide medicine that suits the practitioners’ skills and allows them to work at their optimum level.

Cost management is a key determinant on how care can be delivered and by whom. It affects reimbursement levels and the availability and affordability of private medical insurance.

Fees should be transparent and in ten years’ time it is likely that more care will be self-funded and must be competitively priced. The relationship between public and private healthcare delivery will become blurred and value for money will be a key marker.

This will also impact the decision-making for a doctor about when, if or how to enter private practice. Key changes in employment practices dictated by the NHS may be the catalyst for change in this respect.

If we accept that the current NHS model must adapt or change, it follows that there will also need to be thought given to the delivery of independent medical services. This is not just a London phenomenon and we will continue to see the growth of independent practice in the larger regional centres of the UK.

➱ p30

All applications and data will be held ‘in the cloud’ and will be accessed by much more powerful browsers that can handle all the facilities provided by sophisticated practice management systems

New provider entrants to the UK are already impacting the market and lessening any perceived prior monopoly – a change that is both welcome and energising.

Much is made of issues on medical indemnity and the difficulty in some specialties of accessing affordable or indeed any policy at all. This is a consideration, as it will affect availability of some procedures or indeed some specialties that will simply become too expensive to provide.

The medical defence organisations are no longer the only option and there are emerging and interesting new models of indemnity cover available that do not rely on generic data and can be doctor-specific.

The trend for personal responsibility will continue apace and prevention and wellness will feature more and more. The depth and scope of information that hits us all every day will affect the way we behave and our compliance with personal health management techniques. And we should see a decrease in morbidity in some key areas, but an increase associated with the issues of old age and a different perspective of how to have a ‘healthy’ old age. This will be a very interesting

opportunity for clinicians as they refine diagnosis and treatment pathways to encompass the developing techniques and drug therapies that can eradicate some diseases.

Genomics and personalised medicine will affect treatments to such an extent that, for many patients, it will have life-changing results. The cost, availability and relevance of this will only continue to increase.

Such momentous changes that are often the result of technological innovation affect the whole population and the delivery of care in public and private sectors. The challenge for the independent sector is how we react and adapt to this to retain and maintain a vibrant independent healthcare economy.

The IDF embraces the changes we see ahead and will increasingly be available to clinicians to assist them in embracing these changes to maximise every aspect of their practice.

Thought leadership from clinicians is critical to influencing public opinion, strengthening resolve and providing a united front to the increasing number of stakeholders who affect your practice. Be part of the change; don’t just let it happen to you.

stuart scullion, executive chairman, the association of Medical insurers and intermediaries

In ten years’ time, the NHS will be fundamentally different to the one we see today. It will be:

 More streamlined in terms of infrastructure;

 Better at using emerging technology across many disciplines, especially treatment of cancer;

 Still overstretched with an expectation exceeding capability, and hopefully better funded.

An integrated proposition for social care to support the everincreasing elderly population will be a key component.

The radical view would be for the NHS to provide an A&E service, with the burden of routine and specialist medical procedures shared between the NHS and private sectors based on resource and expertise and with a separate Social Care model.

To achieve this, any Government needs to stop viewing the NHS and private sectors as being in competition. Instead the two must be considered to be complementary to the delivery of a firstclass healthcare system.

The solution is not to tax the death out of the private sector by increasing insurance premium tax.

Healthcare is seen as a vote winner and a vote loser. It is only when a government has the courage to recognise the contribution the private sector makes to the well-being of our population and harness its support that we will ultimately derive the benefit.

Philip housden, Housden Group

By 2028, all NHS hospitals will have an integral private patient unit (PPU).

It will be the accepted norm for around 2-5% of all activity and income in an NHS trust to come from insured and self-paying patients.

This will be because regulatory, governance and patient safety requirements will have driven complex clinical work out of provincial mid-sized private hospitals into clinical centres of excellence where the 24/7 infrastructure is in place and high volumes of activity are concentrated for NHS services. It will be the increasingly ageing population that raises the level of patient comorbidities, increased potential complications and patient risk – these requiring treatment and care at the NHS campuses where there is sufficient resource to cope.

This will represent – at 2018 val-

ues – a three- to five-fold increase in revenues for the NHS from around £650m a year to around £2bn or more.

In ten years’ time, individual NHS PPUs operating alone will be few. NHS PPUs will have federated or amalgamated into regional ‘chains’ and this may have led to the creation of a single recognised NHS private patient brand.

This PPU network will be the dominant provider of high valueadded private care outside of London. In London, the same trends will continue to drive NHS trust PPU growth, but the market will remain different to the rest of the NHS in several respects:

 Strong competition from even more acute providers than now;

 High acuity private hospitals as well as a wide range of niche specialist operators;

 An international patient demand base and individual PPUs with their own strong brands.

Managing a private practice in ten years’ from now

Tom hunt, founder, ppM Software Ltd, www.ppmsoftware.com

The key question is just how far technology can go and I believe there is no known limit.

Just look at how the internet has improved over the last ten years and this will only accelerate over the next decade.

All applications and data will be held ‘in the cloud’, which are just remote servers, and will be accessed by much more powerful browsers that can handle all the facilities provided by sophisticated practice management systems (PMS).

Consultants, practice managers

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and secretaries will be able to access their PMS using much more advanced hand-held devices. Touch-screen and voice technology will revolutionise how we will use a PMS.

Interaction between the consultant and their PMS will be much smoother with direct access for dictation, making the production of letters and reports much less time-consuming.

Communication between the practice and its patients will be more streamlined and totally secure.

And online booking of appointments by patients will become the norm not the exception. This is

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because we now live in a 24-hour society and in ten years it will be even more of a necessity.

Integration between hospital systems and PMS will be developed, removing the need to double-key patient information as is done now.

Secretaries will become much more like practice managers and their focus will be on the administration and patient care aspects of the business.

There will be less need for hard copies of documents, as everything will be viewable on a handheld device.

Because of all the advances

mentioned above, the time required to manage a private practice will be dramatically reduced, allowing the doctor and practice manager much more time for their fundamental role – looking after their patients.

Mr Jerard Ross, Mdu medico-legal adviser

We hope the tragic case of Dr Bawa Garba will prove a catalyst giving politicians the opportunity they need to make changes to procedures for investigating and prosecuting doctors for gross negligence manslaughter.

The MDU is advocating simple procedural changes that should avoid unnecessary investigations and the associated stress for doctors.

In future, doctors should only be prosecuted for behaviour that is the medical equivalent of, for example, intentionally driving down a motorway the wrong way.

In ten years’ time, we hope there will be more proportionate GMC regulation to spare many doctors the stress of an investigation.

There has been recent improvement, but further change is needed. There should be fewer investigations by identifying and closing cases that do not meet the GMC’s threshold and an increase in disposal of cases with a sanction, if appropriate, but without a formal hearing.

The Care Quality Commission also understands the need for more proportionate regulation. But more needs to be done. Its recent review of regulation and inspection has started to make regulation less onerous and it now works with other bodies to take a more consistent approach and decrease demands on practitioners for information.

Claims numbers and costs are rising faster than the ability of independent practitioners to pay for indemnity. This is not sustainable.

It is not the fault of doctors: clinical standards remain demonstrably high, but the legal environment promotes litigation over resolving concerns and is out of the control of doctors.

The MDU is calling for the Government to reform the clinical negligence procedure urgently.

It is good news that it is reviewing the way the discount rate is set and looking at controls on a claimant’s lawyers’ costs, but more radical measures are needed. Independent practitioners need to be aware of and comply with legal and ethical changes.

New data protection legislation and revised consent guidance from the GMC are but two examples.

Philip blackburn, economist and consultant, LaingBuisson healthcare analysts

At a time when there are both clear market challenges and opportunities for UK independent healthcare sector providers, it is little wonder that market developments are moving at a gallop as providers strategise around future customer wants and needs.

Within private healthcare, a customer-centric approach to service delivery and development is expected to develop more earnestly, as providers burrow down the rabbit hole to fully engage with the drivers of private self-pay healthcare demand.

More significant service diversification by independent healthcare providers appears necessary as clinical synergies will drive business synergies to meet customer’s healthcare needs around prevention, intervention, recovery and ongoing care.

The care continuum is the underlying driver of future market developments within the public and private sectors, and independent sector providers will be looking to raise the bar to meet the expectations of healthcare

purchasers, be it insurers, individuals and NHS purchasers.

To this end, a clearer interpretation of service quality and a high degree of information transparency will be a crucial influence on healthcare purchasing in the future.

But with transparency comes only the start of journey. The relationship between price and quality within healthcare is not easily interpreted, and consumer behaviour within healthcare will be constantly developing and changing as purchasers disseminate information and experience.

Private providers, healthcare operators and practitioners alike, will need to get closer to purchasers to ensure healthcare consumer confidence remains strong and they can facilitate drivers of market growth.

Ted Townsend, townsend Strategic advisory Services

The futuristic Star Trek Tricorder had yet to make a real-life appearance by 2018, but, by 2028, it seems unlikely that there won’t be multiple versions on the market.

Of course, they might just be called ‘phones’, but the ability of handheld devices to transform primary care seems just around the corner.

Data collection, diagnosis, drug monitoring, patient management, and lots more could all be immeasurably enhanced with a handheld device, possibly including artificial intelligence.

This will put more knowledge, and power, in the hands of the patient – and GPs, their first point of medical contact.

The need for secondary referrals to consultants for expert opinions could therefore be much reduced and may even reinforce the trend for consultants to concentrate on smaller and smaller niches that, in effect, escape the reaches of artificial intelligence.

Consultants will most likely move to operate more internationally and could be based in more than one country.

The explosion of available data, with cheaper diagnostics, more targeted drugs and improved daycase surgical techniques, could also present a challenge to the concept of a general hospital. More diseases will become

chronic rather than acute, and patients will be treatable in an outpatient/day-case setting, or even at home or work.

The lower capital costs of this could mean different providers entering the market, including more owned by clinicians themselves, although the organisational structures that can deal with this successfully may not have improved in ten years’ time.

There will still be a need for well-managed, well-capitalised hospitals that bring together clinicians in different specialties to treat the more complex patients.

And these hospitals are likely to take on more of the financial risk in treating patients, probably in association with clinicians, with a move towards reimbursement according to diagnostic-related groups, similar to some US and European systems.

The ability, and drive, to measure and reward based on outcomes will encourage this.

There will always be patients who don’t want to travel far and those who will travel anywhere to seek out the best in the world.

But with all the data available to patients, it might not be long before it is the patient who uploads their case to the worldwide web and invites doctors –and maybe non-doctors – to bid to diagnose and treat them from wherever they are in the world. Now, wouldn’t that be futuristic.

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The next decade will see online technology transform the way independent practice works for practitioners and patients, enhancing services and increasing efficiency.

As increasing numbers of practitioners have discovered submitting electronic bills to private medical insurers through the official online clearing system is secure and ensures they can be processed quicker, which, in turn, benefits their cash flow. It means paper invoicing is likely to be a thing of the past in ten years.

However, one of the greatest benefits of online technology is that it has revolutionised the way we access services. ➱ p34

Obviously, the healthcare sector has to tread carefully to support vulnerable patient users, but my next prediction is that practitioners will be utilising technology to provide a better experience, including the convenience of online appointment booking, clarity on treatment costs or even virtual consultations if a patient wants advice or reassurance straight away.

Such advances will require different organisations – practices, insurers and hospitals – to connect and work together more effectively, such as by using a central system to co-ordinate booking. However, connections are already happening through inno-

vations such as Healthcode’s secure messaging services.

There will be a dramatic improvement in the amount and quality of information about independent practice. By 2028,

The Private Practice Register, the central online directory developed by Healthcode, will mean that all the essential information about practitioners is accessible in one place.

As well as streamlining the process of applying for private medical insurance recognition and practising privileges, practitioners will be able to use it to build their profile and to access services such as secure messaging and electronic billing.

Jane braithwaite, managing director, designated Medical William J Mayo’s sentiments reflect the desire of our patients, and seem a sensible objective for us as members of the private medical community: ‘The aim of medicine is to prevent disease and prolong life, the ideal of medicine is to eliminate the need of a physician’.

It is vital to consider the future from the patient’s perspective. What will our patients want in ten years’ time? One way to help answer this is to look at trends on other industry sectors and a generalisation would be that consumers are looking for more control, better information and researching expert opinion themselves.

The wellness industry is booming and individuals are looking to proactively manage their health to avoid becoming sick.

Healthy individuals will be looking for healthcare to ensure they stay well, which will include nutrition, exercise, stress management and traditional medicine.

For those patients who are sick, the treatment plans may well be very different. Technology within a decade will mean that personalised, remote care will be possible – possibly using pre-set algorithms to monitor health with wearable devices.

We will accumulate vast quantities of data for everyone, who will have their own personal data portal to ‘own’ their information. This data may well be shared with numerous experts who will play a part in the overall treatment plan. It is anticipated that some cancers, cardiovascular disease and even asthma may be eradicated in ten years.

Robotic assistants could even replace some tasks that private clinics manage now.

So where does that leave medical professionals?

If some of the work we do now is no longer needed, what can we do to continue to attract patients and have interesting, satisfying work?

It is vital we embrace technology to the fullest and invest time and money into the latest research into nano-medicines, immunotherapy or genetic testing.

We should also consider standing out by working in partnership with other clinics/doctors worldwide, again taking advantage of technology,

But, most importantly, we should listen carefully to what our patients are requesting and adapt to meet their demand, as they are likely to take more control to determine their own pathways to health.

David hare, chief executive, nHS partners network

Patients are rightly becoming ever more demanding about the quality of care they receive and the independent health sector is in a prime position to not only meet, but exceed, these rising expectations in the coming decade.

Independent health providers are already recognised as delivering high-quality, responsive and patient-centred services. But, in the coming years, the focus needs to be on ensuring that care fits around the lives of patients – of which there will be ever-growing numbers with multiple co-morbidities and long-term conditions – and not the other way around.

This will be supported by exciting developments in technology – for example:

 The greater use of artificial intelligence to more swiftly diagnose and predict disease;

 The ability to better monitor patient conditions remotely;

 Innovations such as roboticassisted surgery – all creating huge potential benefits for patient care.

The rising popularity of healthcare apps, such as those providing same-day access to GP services, as well as the increase in the number of people choosing to self-pay, illustrate the public’s growing reluctance to wait ever longer for care.

The challenge in the coming decade will be to ensure that the high-quality and accessible care provided by the independent health sector is not only for those who can afford to pay but that their significant capacity is increasingly used for the benefit of NHS patients as well.

Mike neeb, chief executive, Hca Healthcare uK

Providing healthcare will always be about putting patients at the

centre of everything that we do. In the next decade, developments across science, medicine and technology will enable us to deliver truly individualised care, with even better outcomes.

We are already starting to see how the advent of ‘personalised medicine’ is making a difference in the treatment of cancer.

By studying the genetic makeup of individual tumours, we are able to give drugs that specifically target that cancer and our understanding in this area of medicine is only set to improve.

Establishing new ways to treat cancers is an area of ground-breaking research and development, and it is something we will continue to contribute to through clinical trials at our Sarah Cannon Research Institute.

Outside advances in science and medicine, we are seeing a shift in the way people think about their healthcare, with more and more

people choosing to take control and invest in their health.

In this environment, speed, flexibility and choice are becoming important influencing factors alongside safety and high quality.

It is something we have already responded to by introducing selfpay packages and telemedicine, giving people more choice in the way they access care, without compromising on quality.

In the next decade, we will see continued innovation as we anticipate and respond to what patients need and want from their healthcare.

Dr benjamin holdsworth, director, cavendish Medical

Doctors have witnessed substantial changes to their personal finances in the last ten years, so should assume that the next decade will be equally as challenging.

Two new NHS pensions schemes have been introduced and the limits to tax-free pensions savings – annual and lifetime allowances – have been dramatically reduced.

A harsh new ‘tapered’ version of the annual allowance is now in place, new Clinical Excellence Awards will no longer be pensionable and statutory pension contributions are at their highest level with some individuals facing inputs of 14.5%.

It is difficult for finance professionals to stay one step ahead of every about-turn. So doctors with full-time careers and busy lifestyles will be truly tested to make informed choices without proper guidance.

In the future, we will see changes to working practices with more doctors engaging in private practice employment which will impact taxation and retirement funding. Auto-enrolment means private employees would join company pension schemes.

Doctors will need to consider

multiple funding routes for their retirement to supplement private and NHS pensions and help mitigate tax liabilities.

ISAs, investments and company ventures will prove essential as part of well-structured, well-diversified financial plans.

To navigate ever-more complex rules and regulations, planning early will be key. Every element of an individual’s financial future should work together to secure their long-term wealth.

Dr Andrew Vallance-owen, chairman, private Healthcare information network (pHin)

I believe private medicine has a solid future in the UK. There may be fewer doctors involved because of issues around work-life balance and indemnity costs for young doctors coming through, but there will still be plenty of work for those prepared to take the time to develop a practice.

But developing a vibrant prac-

tice will rely more than ever on showcasing quality through evidence.

While private healthcare has traditionally had a reputation for excellence in customer service, safety and quality, clearly, greater transparency of quality and outcomes is needed to provide reassurance to patients.

The good news is that momentum towards this is well underway with the Care Quality Commission moving towards data-driven inspections and, of course, the important work Private Health Information Network (PHIN) is doing to publish quality indicators for both hospitals and consultants.

Better collection of standardised data and publication of information by PHIN will demonstrate the quality of services consultants provide and enable patients to make informed choices about which providers to use.

The private healthcare sector has a real opportunity to lead the way through listening to patient feedback and routinely measuring positive health outcome data.

This will not only deliver better

As self-pay becomes a bigger part of private practice, more robust billing and collection procedures will be needed

measurement of quality but will also be a clinical tool to improve clinical outcomes across the sector. I believe that, well before the ten years are up, through innovation and open access to clinical information, there will be a radical and positive shift in the way private healthcare operates for patients.

Martha Walker, independent medical management consultant, cQc consultancy Alongside Independent Practitioner Today, The Health and Social Care Act is also celebrating its tenth year.

The Act has been back to Parliament for amendments to meet the fast-changing face of health and social care.

One of the most significant changes in the last ten years is also the one that I believe will grow and develop the most in the next ten, challenging the Care Quality Commission’s (CQC) capability to keep in step with the evolving world of medicine.

The last three years have seen an enormous increase in the provision of remote and telemedicine. I think it would be fair to say that

the introduction of digital platforms to access a GP consultation caught the CQC off guard.

In future, clinical apps to read blood pressure, take temperatures and measure heart rate will become normal practice for people to carry on their phones and have them linked to their medical records held by their GP and then discussed with their GP via their iPad.

To its credit, the CQC is now working with remote medical providers and bodies such as the Independent Doctors Federation to develop a practical and effective inspection programme for digital medicine.

The watchdog has in place a digital department with forwardthinking doctors, but the stumbling block will be down at inspection level.

The CQC’s knowledge base must extend to the inspectors who need to be up to speed on the latest con-

sultation methods and are not prejudiced to innovation.

So often new and innovative healthcare starts in the independent sector, so it will be the independent doctors who will have to explain the efficacy of a new mode of diagnosis or consultation that is yet to be embraced by the NHS.

Without suitably trained and qualified inspectors, the doctors may well find themselves appealing against inaccurate ratings made on the basis of a lack of comprehension by the inspector.

So, at the top of my wish list for the CQC in the next ten years is, quite simply, better trained inspection teams.

All too often I hear about huge discrepancies in inspection team knowledge and doctors who have had to present extensive evidence to support their clinical decisions before the inspector will withdraw inaccurate comments from the draft report.

This process is usually very distressing and time-consuming for the doctor and often leaves the doctor questioning the value of the work they do. Without properly trained inspectors, the advances in delivery of healthcare may well be stifled.

Findlay Fyfe, managing director, Medical Billing and collection

None of us has a crystal ball, but there are ongoing trends that it is fair to expect to continue.

Firstly, with the advent of the Private Healthcare Information Network and the requirement for doctors to display their fees from 2019 with the idea of improving patient choice, I would expect a level of ongoing pressure from the market to limit fee growth.

Secondly, the growth of the selfpay market ,which now accounts for over 50% of our billing. This increase has been driven by people

taking a ‘pay as you go’ approach to private healthcare and the increase in shortfalls as the insurers pull the belt tighter.

I would expect self-pay to become a bigger part of everyone’s practice. This will inevitably lead to a greater requirement for robust billing and collection procedures at your practice.

That leads into my third point, insurers. We would expect a continued push from them to try and maintain the lower remuneration paid to private practitioners.

I would also expect to see more insurance companies coming under the umbrella of the bigger insurance companies and having their payment structures taken on.

Again, this will prove the need for a robust approach to billing and collection procedures to ensure the value of payments from insurers is maximised.

Fourthly, we would expect a ➱ p38

“MedSecretary have gone above and beyond my expectations. their services to anyone”

continued shift away from defence unions to insurance companies for medical malpractice insurance for both the security cover and cost savings.

Rosemary hittinger, associate adviser to the Federation of independent practitioner organisations (Fipo)

The tectonic plates of private medicine, its focus, its funding, its regulation, its practitioners – coupled with an increasing demand for transparency – are shifting rapidly such that the private healthcare market of the future will look very different from today.

Private practice as it is currently understood, with most consultants operating independently or in a group arrangement, will change, driven by the cost of professional indemnity and insurance pressures.

In many specialties, consultants will be subject to new models of reimbursement including salaried employment within the sector.

This will necessitate a balancing act between professional autonomy and demonstrable quality and value.

Following examples from the US, there will be a tendency towards more medically qualified senior managers in the sector and the clinician-led provider will become established.

Clinicians will be more effectively engaged in the strategic oversight of service provision and develop paths for better integration into existing both public and private services.

Much will depend on how the NHS develops and how its relationship with the private sector, which has always excelled at patient-centred convenience, evolves.

As the funding barriers between public and private sector become more permeable, there will be increasing use of private investigative and diagnostic modalities. Patients will flip between the sectors and new technologies will be adopted to allow for better coordination and maintenance of personal records.

Insurers will need to adapt their products to this changing consumer demand. In fact, if newer

and more affordable and transparent private medical insurance products are developed, we could see a marked expansion of the private healthcare market.

Urgent care will be more frequently accessed privately with more affordable models and options being developed by providers. However, the current UK geographical variations in independent healthcare provision could become accentuated.

The demand for both quality and financial transparency means that a new type of staff support will evolve to capture, validate and submit clinically rich, relevant and accurate information on behalf of individual consultants and hospitals to external bodies, including professionally-led national audits.

tals will undoubtedly be strengthened. Entrants coming in to the UK market recognise the importance of working more closely with consultants to manage adherence to care pathways and rigorously monitoring care outcomes.

This will improve consistency in care and support the adoption of new models of care which will, in turn, improve affordability for customers.

Excess capacity and ageing facilities are a driver of significant inefficiency.

I therefore expect to see consolidation in the number of facilities and also in the number of consultants.

Whatever NHS renewal will mean by that time, there will be a place for the private sector to work with it for the delivery of excellent medicine and a better health for all. The old pejorative and political divide between public and private will have gone.

This transformation will be forced by the patient’s needs and demands. The patient of 2028 will be more selective. He or she will be connected and more aware of treatment availability. There could be more international patients as the results of the opportunities Brexit will bring.

The patient of 2028 will be a self-payer or have an insurance better tailored for modern care. There will be more self-referred patients and the idea of GP referral may have vanished by then.

The future will belong to practitioners who establish understandable and relevant measures, such as long-term sepsis rates or cancer survival rates, that prove the value they provide for their patients.

So long as the private sector manages to retain the ethos of highly personalised convenient care led with professional autonomy and judgement, then far from being in decline, we could see an upsurge in utilisation in the longer term.

James sherwood, director of health and benefits management, Bupa uK

Private healthcare in the UK is at a turning point. Much has changed over the past ten years – from the introduction of new diagnostics and medicines through to advances in treatment and technology. However, the underlying structure of the private system remains largely unchanged.

This will not be the case over the next ten years. The Patterson case and recent Care Quality Commission report through to NetCare’s decision to leave the UK and further leading foreign healthcare providers’ entry into the UK market will be a catalyst for change.

Governance over care in hospi-

In the long term, this will be beneficial with fewer, busier hospitals and consultants enabling more effective governance, better outcomes and more cost-effective care for customers.

We will also respond to rising customer expectations. Crucially, I expect insurers and hospital providers will seek to redesign processes and systems around the customer, enabling a simpler and enhanced experience when accessing and claiming for care.

The sector is at an interesting juncture. While we will need to question long-held beliefs and established practices to deliver the improvements customers are expecting, I’m confident the sector will rise to the challenge.

Dr Alix Daniel, private Gp and medical director, Foresight Medical centre, London

I can see major opportunities for UK private healthcare, with the possibility to deliver truly patientcentred care where precision medicine, the development of a kind professionalism and digital healthcare will translate into safer and more efficient medicine.

Brexit, NHS renewal, digital transformation, precision medicine and new medical challenges as the result of global warming and an ageing population will all influence a necessary, renewed private healthcare.

Digital transformation will help continuity of care. Telemedicine and patient-owned records could be part of daily care.

By then, the GMC will hopefully regulate private insurance, digital healthcare providers and alternative medicine to protect not only the patients but also doctors.

Healthcare staff will be specifically trained for private healthcare and robot receptionists may welcome patients by that time.

A niche for excellent private GP care outside hospitals will thrive with independent small practices offering a personalised service with well-trained staff, prompt diagnosis and a close co-operation with consultants and private hospitals.

This may be a dream, but I just cannot wait for this to happen and forget about the gloomy days of 2018.

Jeremy

hunt, Health Secretary Independent Practitioner Today invited Health Secretary Jeremy Hunt, while at a London Consultants Association meeting in April, to tell us how he saw private practice in ten years’ time. We also made the same request through his assistant PA. No contribution was received. At the meeting, he was due to speak on the future of NHS and private healthcare. But, at the event, it was announced he had changed the title of his speech, leaving out the private sector. 

ThE hiSToRy oF mEdicinE

Take this ‘slug’ of

Medical historian

Suzie Grogan (below) unearths what today’s surgeons and GP predecessors were treating – and charging – in the 18th and 19th centuries

☛ Adapted from Death Disease & Dissection – the life of a surgeon apothecary 1750-1850, by Suzie Grogan. Pen & Sword Books Ltd, ISBN 1473823536, Price £12.99

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From the 21st century and the medical advances we enjoy now, it is both horrific and fascinating to learn about the conditions, concerns and ‘cures’ that were part of life –and death – for our forebears.

prevalent in the 18th and 19th century we rarely see today. Some have different names and many are now deemed to be minor inconveniences rather than lifethreatening conditions.

the treatment of some of these conditions until the development of antibiotics in the 1920s, and some were still causing death and lifelong health problems well into the 20th century.

early 19th century medic hope to ‘cure’? In

General Practitioner 1750-1850

Irvine Louden states that the only specific treat ments that we would consider useful in the 21st century are qui nine (effective in treat ing malaria), digitalis (to treat dropsy, possibly as a result of heart failure), fresh fruit and vegetables (for scurvy and their obvious health benefits) and opium (as a pain relief, a sedative or even as a stim ulant).

cine developed in this period saved millions of lives.

regularly offered by doctors is examined, there was, at best, a vast quantity of generally harmless but unnecessary – and often ghastly – medicines consumed and, at worst, a number of potentially deadly poisons taken.

For example, the old operating theatre museum in London’s St thomas Street offers an 18th century recipe for the treatment of a ‘venereal disease’: snail water.

SNAIL WATER

² Take Garden-Snails cleansed and bruised 6 gallons,

² Earthworms washed and bruised 3 gallons,

² Of common Wormwood, Ground-Ivy, and Carduus [Aster], each one pound, ² Penniroyal, Juniper-berries, Fennel seeds, Aniseeds, each half a pound, ² Cloves and Cubebs [a pepper] bruised, each 3 ounces,

² Spirit of Wine and Spring-water, of each 8 Gallons,

² Digest them together for the space of 24 hours,

² And then draw it off in a common Alembick (a still).

mony, mercury and many others when needful, of course, employed … but the great bulk of bottles were mere placebos…’ (from Louden p 64).

When the dispensing of medicines formed the larger part of a medical man’s income, it is possible some were exploiting the health anxieties of their patients, particularly if they were physician to a wealthy family or individual.

o nly a minority of doctors charged for the medicines alone – most would add a call-out fee and additional charges should procedures such as bleeding, or a clyster (an enema), be required.

But with a population prone to hypochondria and with death ever present in their lives, it is hardly surprising if, when a livelihood depended on it, a doctor prescribed a potion or lotion not yet proved to be efficacious. Besides, as in the 21st century, the placebo effect often produced seemingly good results.

elpless as they were in the face of infections, fevers and countless other debilitating diseases, doctors resorted to preparations that they knew offered, at the very least, comfort to the concerned patient.

For many, the mere presence of the doctor by the sickbed produced restorative effects and much of their work was simply to reas-

Surgery

London surgeons were known to charge hundreds of pounds for an operation, but these were not to treat conditions most often seen by the local GP.

h is surgical work was regular and payment was often for small amounts. t he fees, if not the treatment, were broadly the same for both rich and poor patient, and across the country.

For example, William Pulsford of Wells charged one-and-a-half guineas to treat a child who had dislocated their wrist falling from a tree and five guineas for a gunshot wound to the hand.

opening an abscess could cost anything from five shillings to one-and-a-half guineas, and the on-going treatment for an ulcerated leg cost 14 guineas over twoand-a-half years. Parish work was charged out at the same rate as private work and in 1757, it made Pulsford more than 20 guineas.

A GP’s income was dependent on fees from a number of different sources and William Pulsford was practising at a time when the old Poor Law administration was still relatively generous.

As competition grew, fees could not go up in line with increased costs, so it is difficult to compare the fees of 1757 with those of later periods.

however, five shillings paid in 1757 would be worth approximately £20 in 2015 and might be two days wages for a skilled artisan of the time.

The man-midwife

By the end of the 18th century, local GPs or surgeons had taken on this role, at least in market towns and more rural areas. there may still have been a fair ratio of midwives to doctors, but by the turn of the century, it was rare to find a surgeon-apothecary who was not also a man-midwife.

Surgical tools for obstetric use

During the 18th century, the rise of obstetrics as a suitable subject for study and the role of the midwife proper for a man was dramatic. In an increasingly competitive market, it was a new discipline to seek expertise in and an area within which, if successful, a new and fruitful source of patients would result. many people felt strongly that the place by the side of a woman during childbirth should be taken by a woman. there was not just

l

structuring

l Solvent liquidations

l consultant groups and consortia

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anger from midwives, who saw their position taken away. many doctors felt that attendance at a long, and probably natural, labour was a waste of valuable time, which a doctor could better spend on other patients who needed him for a genuine medical reason.

others felt there was something ‘unmanly’ about a doctor who wanted to take on this role. Some thought there were what we would now refer to as gender politics involved, in that, as a man had been the primary cause of the discomfort and any possible complications, he could not justify further intervention.

t he significant rise in importance of the man-midwife is all the more remarkable for the lack of support offered by the colleges and corporations for those taking up obstetrics.

Scotland accepted the importance of the subject to their stu-

dents and offered courses in obstetrics long before it was accepted south of the border, where arguments about who was responsible for training also held up education and research.

t he physicians at the r oyal College believed the messy business to be the province of the surgeon, although they would deign to be involved if there were problems during the pregnancy or after the birth.

Lower ranks

Surgeons were not keen to take on the role either. the Company of Surgeons, later the royal College of Surgeons, wanted to restrict their members to undertaking ‘pure’ surgery, but, in reality, neither branch of the profession considered it a ‘manly’ role and it was therefore work only fit for the lower ranks.

this attitude continued into the 19th century and eventually, the

role became one central to the general practice.

It was, of course, easier for the female midwife to examine a woman fully. Some allowed the woman to choose the birthing position she found most comfortable and the birthing stool was a common item used, offering a comfortable position and allowing gravity to assist in the delivery.

an 18th century birth scene (left) and a doctor of that period performs an internal examination (below)

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As the male midwife became more common, the generally accepted position for delivery was changed to one that many would find far less comfortable. t he woman had to lie on her side, with her face away from the doctor in attendance.

charming manner

Doctors were also more reluctant to undertake abdominal examinations in case it led to accusations of impropriety, an issue that could lead to life-threatening misdiagnosis.

A man must also develop a charming bedside manner to ensure the patient’s confidence and many did this by ordering about the female nurse – who might once have been the midwife – or lady’s maid. midwives of the early 18th century sensed that they might be partly responsible for the ‘fashion’ for having a man at the birth. Lack

of confidence in difficult cases often led a midwife to call in a doctor before it was necessary and thus pass any credit for her own skill to the man-midwife.

It seems likely the male midwife was better able to listen to a woman’s general concerns about the medical aspects of childbirth and able to calm them, seeming to be more of a friend than a nurse.

Women were, and still are, influenced by their friend’s experience of childbirth and once a man-midwife had safely delivered a number of babies in his area, he was most likely the subject of conversations at female gatherings. m anmidwives did rather well by wordof-mouth recommendations.

But the man-midwife was not always the triumphant master of his female counterpart. For many doctors, the role was an unpleasant chore; something that had to be taken on if the practice was to be profitable.

‘the man-midwife … cannot be compensated at all by the mere lying-in fee, unless it leads to other business. I know of no surgeon who would not willingly have given up attending midwifery cases provided he could retain the family in other respects…’ (Richard Smith of Bristol, quoted in Louden).

Without sleep

Certainly, in many country areas, the doctor had to attend when called, regardless of whether his skills were required or not.

m atthew Flinders of Lincolnshire notes in his diary that he had spent 40 hours without sleep, attending two normal births. this was at a fee between just 10s 6d and a guinea per case.

Looking at the Weekes family letters, it was clear that they charged a higher fee to wealthier patients – 15s for a parish baby and five guineas for delivery to a

wealthier family, although the higher fee would doubtless include considerably more antenatal and post-natal care and attendance at false alarms could not be charged as extra.

other records, such as those of Danvers Ward of Bristol, indicate that a man may work in the field simply for the love of it. Ward was clearly keen on the obstetric arm of his practice. records show that over a third of his cases were obstetric and in one year he delivered 121 women, at a fee of between half a guinea and three guineas.

And despite the lengthy period usually necessary to deliver a baby and the speedy nature of many of his other non-obstetric cases –dental extractions and abscesses for example – his average fee in both cases was around 14s 6d. h e, and other doctors, also delivered babies free of charge to the poorest families, indicating a genuine love for childbirth.

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Death certificate hitch

Dr Catherine Wills (below) responds to a private GP’s query about providing additional information following completion of a Medical Certificate of Cause of Death

Dilemma 1 Was death due to something else?

QOne of my elderly patients has recently died. She had terminal cancer and was receiving palliative care at home.

I had seen her about five days before her death and had prescribed some antibiotics for a chest infection. Her symptoms deteriorated during the night and she was taken to the A&E department by her son.

She sadly died not long after her arrival. I was asked by the Coroner’s office to sign the death certificate and after discussion with the doctor who treated her that night, her son and the Coroner, it was agreed appropriate for me to sign the certificate and provide a cause of death.

I have just spoken to her niece who was also present at the time of death. She told me the doctor had diagnosed pneumonia and prescribed intravenous antibiotics. A nurse had begun to administer these when the patient said she felt unwell and deteriorated very suddenly, before suffering a cardiac arrest.

No attempts at resuscitation were made, as a DNAR order was in place and the family agreed with this. The niece was concerned that her aunt’s deterioration seemed to coincide with the administration of the antibiotics and that these contributed to her death, but there was no reference to this in the notification of death form I got from the hospital.

The niece did not want me to speak to the Coroner about it and the son and other close family members did not want a post mortem examination carried out. I do have sympathy for the niece, but I am not sure what my obligations are now that I have been told this information.

AIt is important that you are honest and trustworthy when completing or signing forms and, at the time you signed the original death certificate, you did so in good faith, based on the information you had at the time, and in agreement with the other parties.

However, you now have additional information which may be relevant to the patient’s death.

The GMC states that you must make sure that documents you write or sign are not false or misleading. It would expect you to take reasonable steps to check that any information you provide is correct and that you do not deliberately leave out any relevant information.

As the information provided to you by the patient’s niece might be relevant, you should inform the Coroner’s office about this so that the Coroner can decide if this needs to be investigated further.

The GMC expects doctors to cooperate with formal inquiries, such as Coroner’s inquests, and doctors must offer all relevant information. The conversation you had with the patient’s niece should be recorded in the patient’s records.

Although you are not obliged to tell the niece that you intend to contact the Coroner with this information, it would be appropriate to explain to her why it is necessary for you to discuss her concerns with the Coroner and apologise for the inevitable inconvenience this may cause.

Having discussed this with the Coroner’s office, you should follow its advice about the next steps and document this in the records. If you did not disclose this information and it came to light later, then you could be criticised for not having complied with your GMC obligations, which could potentially lead to the GMC conducting its own investigation into your fitness to practise.

His dying wish

A patient’s request to his private GP over an ‘advance decision’ throws up some difficulties. Dr Catherine Wills gives her view

Dilemma 2

Must I assist him with ‘living will’?

QI am a private GP and have been asked by one of my long-term patients to help him set up a ‘living will’. Both of his parents died from terminal illnesses and spent a considerable amount of time in hospital having palliative care.

He was very distressed about this at the time and does not want this to happen to him. Although he has no medical problems at the moment and is generally fit and well, he wants it on record that he would not want treatment if he was terminally ill and couldn’t make decisions for himself.

I feel uncomfortable about this, as he is currently well. Do I have an obligation to assist him?

ASince the introduction of the Mental Capacity Act 2005, the concept of a living will has been replaced by the ‘advance decision’ to refuse treatment.

This allows for a person to specify that a particular treatment should not be carried out or continued if, at a later time and in accordance with specified circum-

The patient may be better placed to arrange a lasting power of attorney for their personal welfare, which would include medical treatment

stances, the patient lacks capacity to make that decision for themselves.

The difficulty for this patient is that for an advance decision to be valid and applicable, the treatment needs to be specified, as do the specific circumstances, in the decision itself.

This might apply, for example, where a patient suffers from a condition such as motor neurone disease and can reasonably foresee what clinical course their illness is likely to take.

As this patient is not currently unwell and does not have a specific diagnosis, it is difficult to see how they could create an advance decision that could cover every eventuality to the extent that it could be regarded as valid.

If there are reasonable grounds to suspect that circumstances exist that the patient would not

have anticipated, this may invalidate the decision.

Rather than an advance decision, the patient may be better placed to arrange a lasting power of attorney (LPA) for their personal welfare, which would include medical treatment. The patient could appoint an attorney who could make certain decisions on the patient’s behalf.

This would only apply once the patient had lost the capacity to make decisions for themselves and the attorney must act in the patient’s best interests.

The patient would need to ensure there was extra provision in the LPA to confirm that they authorised the attorney to make decisions about life-sustaining treatment, in addition to any other treatment that they might require. 

Dr Catherine Wills is a medico-legal adviser at the MDU

‘Hanging in there’ is the key to investing

How can you as an investor survive inevitable falls?

Patrick Convey (below) explains why you should lean on your financial planner

Investors have experienced very strong investment markets since the Credit Crisis a decade ago. some may have forgotten –or never experienced – the pain and even fear that such events can induce.

When falls do happen, how investors behave will have a great bearing on the longer-term outcomes they will experience. today, £100 invested at the bottom of the global equity market fall in March 2009, would be worth around £345 before inflation and any costs.

It is important to remember that equity market falls are an inevitable part of the process of building wealth through equity ownership. how can you put market falls in perspective and learn to survive them?

s ometimes it helps to remind ourselves why investors deserve positive returns from ownership stakes in companies (equities) and lending their money to governments and corporations (bonds); it is because the outcome that they will receive from their investments is uncertain.

t he future dividend stream from equities is, intuitively, far less certain than the contractual payment of coupons (interest) and return of principal at the maturity date of a bond.

the greater the uncertainty of the outcome, the more an investor needs to be compensated with higher returns. the market’s view on the ability of a firm to deliver dividends – impacted by multiple factors, such as management strength, strategy, competition and the state of the economy, plus its perception of risk – can have a large

impact on the price of a share, leading to share price volatility.

If returns went up year in, year out, there would be no uncertainty of outcome and investors would be lucky to generate a return much higher than inflation. Longer-term investors should embrace – and learn how to survive – this shorter-term uncertainty, as it is the basis of strong longer-term equity returns.

You have got to be in it to win it

If we looked at the monthly returns of global equities from January 1999 to February 2018, we would notice that markets are very volatile every month. there are almost as many ‘down’ months as there are ‘up’ months.

secondly, ‘hanging in there’ –through thick and thin – is worth pursuing; £100 invested in January 1999 more than tripled in value by the end of February 2018.

It would be wonderful if someone rang a bell to tell investors when to get out of the market and rang it again to tell them when to get back in; but it is evident that picking the month, or even year, to do so is well-nigh impossible.

But even if you had ‘got it wrong’ and invested at the very height of the market, just before the tech Wreck (2000-2003) and the Credit Crisis (2007-2009), your £100 would still be worth £232 (4.9% p.a.) and £227 (8.3% p.a.) respectively at the end of February 2018. the key message is to remain invested.

It can be unsettling to look at the value of your portfolio too often. even the data you see at a progress meeting with your

adviser, six monthly or annually, is largely noise and your portfolio is likely to be down on one in three visits to see them.

True bear markets those participating day to day in the markets or commentating on them (‘Billions of pounds wiped off UK shares’) risk failing to see the wood for the trees and tend to induce feelings of panic, concern and sometimes even hysteria over short-term falls. Much of the time the doom-mongering is overdone. t here will always be periods annually when markets fall below their high point. Listen to this noise and you spend most of the time afraid of markets instead of embracing them.

thirteen out of the last 19 years (1999 to 2018) have delivered positive returns, despite suffering intra-year falls from the market high that year. Generally, investors should expect a down market one in every three years or so. take 2009 as an extreme example. During the calendar year, the global markets suffered a loss of nearly a quarter of their value, yet finished the year up almost 20%. selling out and missing the rise would have been extremely costly. Likewise, in 2016, the market fell almost 10% during the year, but ended up over 28%. If investors panic when markets fall – perhaps switching into cash – they will inevitably suffer financially and emotionally on many occasions, when staying invested would have been the right thing to do. responding to short-term market noise is to be avoided at all costs.

sometimes these falls can con-

Ten Things To remember when markeTs fall

tinue from one period to the next, turning from short-term noise into medium-term bear markets. the trouble is that by the time you can see that it is more than a very temporary downturn, it is too late. r emarkably, and sadly, U s investors in equity mutual funds made record withdrawals coinciding with the bottom of the markets during the tech Wreck and Credit Crisis. Buy high, sell low is a strategy that guarantees wealth destruction.

do, rely on the structure of your portfolio to see you through. Don’t panic. Investors who have fortitude, discipline and patience will fare best. t hose who need support should lean on their adviser – that is what he or she is there for. 

Patrick Convey is technical director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS.

1 embrace the uncertainty of markets – that is what delivers you with strong, long-term returns.

2 Do not look at your portfolio too often. once a year is more than enough.

3 accept that you cannot time when to be in and out of markets – it is simply not possible.

4 if markets have fallen, remember that you still own everything you did before – the same number of shares in the same companies and the same bonds holdings.

5 a fall does not turn into a loss unless you sell your investments at the wrong time.

6 falls in the markets and recoveries to previous highs are likely to sit well inside your long-term investment horizon – that is to say, when you need your money.

7 The balance between your growth (equity) assets and defensive (high-quality bond) assets was established by your adviser to ensure you can withstand temporary falls in the value of your portfolio, both emotionally and financially, and that your portfolio has sufficient growth assets to deliver the returns needed to fund your longer-term financial goals.

8 be confident that your (boring) defensive assets will come into their own, protecting your portfolio from some of equity market falls. be confident that you have many investment eggs held in several different baskets.

9 if you are taking an income from your portfolio, remember that if equities have fallen in value, you will be taking your income from your bonds, not selling equities when they are down.

10 Your adviser should be there – at any time – to talk to you. he or she can act as your behavioural coach to urge you to stay the course.

If market timing were so easy, it would be simple to make vast amounts of money and there would be few professional fund managers left. they would all be sunning themselves on their yachts in the Caribbean. owning equities in portfolios is not easy. Yet, the very nature of the uncertainty of outcomes is why decent returns can be expected from owning them. Markets will fall at some point and when they

The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions. Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.

Plenty of PPU potential

Our tour of private patient units (PPUs) continues this month as Philip Housden looks at the private patient services in the 17 NHS trusts delivering acute care services to the south-west counties of Dorset, Devon, Cornwall, Wiltshire, Somerset and Gloucestershire

Figures F rom the published annual accounts for this group of trusts shows that total private patient revenues have been essentially static for the past three years from 2013-14 to 2016-17 at around £31.5m a year (Figure 1).

This now represents 0.61% of these trusts’ total revenues, a gently falling trend over the period. The combined national average outside of London is 0.5%.

These 17 acute trusts can be divided into four groups based on analysis of private patient revenue growth and by percentage of overall trust patient incomes (Figure 2):

 Growing faster: Three trusts have grown by more than 10% in the past three years and, in these trusts, private patient revenues now account for over 0.9% of total trust revenues. These are: salisbury, swindon and Taunton;

 Growing more slowly: six trusts have growth of over 10% in the past three years, but all remain at less than 0.6% of trust revenues;

 Static: Two trusts have held steady through recent years: Dorset County and Yeovil;

 Falling: The final group is made up of the six trusts that had between them £3.1m a year lower revenues last year than in 2014-15. of the fastest-growing trusts, all have a dedicated private patient ward, although salisbury’s is small with four dedicated beds in the Clarendon s uite, with revenues supplemented by diagnostic and other earnings and a focus on growth.

Taunton has been growing fastest in the region because of a clear focus on development. The trust has invested in the 12-bed Parkside u nit PP u at m usgrove Park Hospital and also in a com-

mercially focused management and support team.

s windon’s PP u service, now branded shalbourne Private Health Care, provides a dedicated ward of 20 beds. growth potential may not yet be fully realised, in part due to changes of management over the last few years and also a weakening of ring-fencing of private capacity in recent times. (Figures 3 and 4).

Holding back

in the next group, there are five trusts with growth, but all share the same factor that this is from a low base, as none earn more than £2m a year presently.

university Hospitals Bristol generates over £1.5m a year without a dedicated private patient unit. it is understood that each service division operates separately with respect to private patient activity and this lack of central cohesion may be holding back growth.

Although private patient activity accounts for around 1% of total revenues and is above the NH s average, in comparison with neighbouring North Bristol, the trust seems to be missing an opportunity. This is most likely to be in complex surgery requiring critical care back-up – and this is in spite of the presence of relatively strong private hospitals in the city.

However, uH Bristol is expected to incorporate Weston Area NHs Trust, and this provides an opportunity for a rethink and opportunities to invest for growth. Although small, Weston’s Waterside suite has delivered a local private patient service, and the combination of the two trusts’ private services could result in a ‘chain’ opportunity, should the top team wish to invest.

r oyal u nited Hospitals Bath operates in one of the most competitive private hospital markets outside of London. The trust is growing private patient revenues, but from a low base.

There remains local market potential because of the relative affluence and size of the drivetime catchment. However, it is understood that, despite this potential, the trust presently has no plans to invest in dedicated private patient capacity.

By contrast, the r oyal Devon and exeter has invested in dedicated management and has built up momentum with growth in each of the last three years. i ndeed, the trust has recently announced investment of £1.8m to open a new 12-bed PPu inpatient ward in the autumn of this year. The trust has ambitions to at least double present revenues through this investment.

Along the coast, and presently the lowest revenue earner in the region by percentage of trust income is Torbay and s outh Devon. The relatively weak local independent sector and the opportunities that may present

working through the recently announced strategic estates partnership might lead to a local capacity offer.

Unmet demand

Certainly, local market reviews have demonstrated that there is an unmet local demand for a range of higher complexity activities. Perhaps there is room for a future link between the new service in exeter and Torbay? o ther trusts growing private patient incomes by over 10% but from a very low base are Northern Devon and royal Cornwall. in North Devon, the trust used to have a PP u but has for some time used the capacity for NH s activity, and despite local consultant support, the market seems too small and geographically isolated to achieve anything easily on their own. Truro has the joint lowest overall percentage of revenues with Torbay.

ramsay’s Duchy Hospital is near the hospital and in a good position to exploit NHs capacity constraints. There are no presently declared plans by the trust to develop a local private patient service.

Figure 1

There are two hospitals holding their own in revenue terms: Yeovil and West Dorset. Yeovil is a small trust with several examples of successful commercial developments, including the 14-bed Kingston Wing.

The trust still enjoys the highest percentage of trust revenues in the s outh-west, but, since a change in manager, has been going backwards.

Dorset County is keen to develop private patient services, most likely through the strategic estates development partnership recently agreed.

Declining revenues

We now turn to the seven hospitals with declining private patient revenues.

With a similar demographic to Bath, at least in parts, gloucestershire Hospitals has managed a long-term decline in private patient earnings over several years. i n 2011-12, the trust had private patient revenues of £3.4m (0.78%), but by 2016-17 this had fallen to £2.9m (0.58%).

The trust continues to struggle to find a workable design solution for delivering dedicated private inpatient capacity. The Cheltenham general site in particular has strong potential, which would be delivered if the 15-bed Knightsbridge Ward was still fully available for private patients.

g loucester is not as strong a catchment area, but the r oyal infirmary has the surgical infrastructure to offer the high-quality patient safety back-up that clinicians value.

This story of slow decline is mirrored in a number of other trusts. Poole invested in the Cornelia suite, a dedicated six-bed PPu in 2013 and this initially led to significant growth. However, a change in trust leadership followed and the unit has not enjoyed the same support in recent years.

Nearby Bournemouth is now moving ahead with new management after a disappointing few years. Perhaps this is another geographical location where trusts could work together at least in private patient services. s adly, Plymouth essentially closed their successful private patient ward, The meavy Clinic, a few years ago. With a teaching

hospital catchment, this is an underdeveloped market opportunity, especially for complex work, and the present situation is disappointing, as the potential to increase income is significant.

Market niches

Finally, North Bristol may be the highest-earning trust by revenues in the region, but it too has a slow decline when looked at as a percentage of trust incomes.

The trust has recently appointed new private patient managers, but again there are no known plans for a dedicated PPu and, without

this focus, future growth is likely to be limited.

it is recognised that the southwest is not the strongest market for private patients, but across the region most of the NHs trusts are in a good position to exploit the important market niches for services that the independent hospital provider groups can’t provide. so present trust earnings essentially reflect the level of investment in capacity that a trust has made or not made. The assumption is, therefore, that with the ageing population, increasing patient safety agenda and increas-

ing restrictions on NHs access and lengthening waiting times, there remain opportunities for all these trusts to examine PP u growth, particularly in complex procedures and for self-pay patients. i mportantly, the s outh-west is the home of the only surviving regional group of NHs PPu managers and this supportive network provides a significant level of peer group self-help to the range of middle managers tasked with delivering private patient services where they are such a small, but important part of their trust.

 Next month: East Anglia

Figure 2

Figure 3

Figure 4

Philip Housden (above) is a director of Housden Group

A PRivATE PRACTiCE: CAPiTAL gAiNs TAx

Do you know what you pay tax on?

Capital gains tax is one of the less common taxes people pay, but it can sometimes be an unexpected and unwelcome tax that can catch you out. Ian Tongue explains the basics of the levy and some common areas where capital gains tax can arise

What is capital gains tax?

Capital gains tax (CGT) arises on gains from capital assets, in contrast to income tax which is largely paid on earnings and savings.

CGT can be a complex tax and historically the calculations were quite involved, but fundamental changes were introduced in 2008 which did simplify matters, for individuals at least.

For an individual, the rate of CGT paid is dependent on whether they are a basic-rate or higher-rate taxpayer to either pay the standard rate of CGT or higher rate of CGT respectively.

These rates are:

❒ Standard rate 10%

(18% on residential property);

❒ Higher rate 20% (28% on residential property).

Each individual has an annual tax-free allowance for capital gains without paying any CGT and this is £11,700 for 2018-19.

For a company, there is no annual tax-free allowance and

CGT is usually paid at corporation tax rates, currently 19%. But there are exceptions to this, such as high-value property held in a limited company, where the rate is 28% in line with the higher rate for individuals.

When is it paid?

The most common scenarios that I come across with my own private doctor clients is on the disposal of residential property that was historically their home or has been held as a buy-to-let property, and the liquidation of their limited company.

Other common scenarios are on the sale of stocks and shares that are not sheltered from tax, for example, not in an ISA or tax-efficient investment product.

Note that certain investments can be sold as tax-efficient but later not satisfy the criteria, and a good example of this is an enterprise investment scheme (EIS) that fails.

Other more common areas where CGT is paid would include:

 Antiques, jewellery and other personal possessions if they are worth more than £6,000;

 Business assets;

 Overseas assets if you are tax resident in the UK.

Common areas where CGT is not paid would include:

 Cars – including appreciating classic cars;

 Antiques, jewellery and other personal possessions if they are worth less than £6,000;

 Stocks and shares in tax-efficient savings plans such as ISAs;

 Gains on investments qualifying for special treatment, provided all criteria are met – for example, a company listed in the Enterprise Investment scheme;

 UK government securities;

 Betting, lottery or pools winnings;

 Personal injury compensation;

 Foreign currency used for own or family use outside of the UK.

How is it calculated?

For individuals, the calculation became more straightforward following the capital gains tax simplification exercise in 2008. It now simply deducts what you paid for the asset from the selling price, net of selling costs, and applies the appropriate rate of capitals gains tax.

An example for a buy-to-let property owned by an individual who is a higher-rate taxpayer and never lived in the property would be:

Selling price after selling fees:

Less cost price

Capital gain

£500,000

(£250,000)

£250,000

Less annual allowance (£11,700)

Gain subject to tax

Tax payable at 28%

£238,300

£66,724

For companies, the calculation is different, as the ‘cost’ price is given an inflationary adjustment to uplift original cost, which is known as ‘indexation’. The calculated gain is subject to corporation tax and no annual exemption is available.

Capital gains tax relief

There are reliefs available to reduce the gain made or – in the case of certain business assets – to defer the gain to a later period by re-investing the gain made on qualifying assets.

For individuals, the most common CGT reliefs that are appropriate are:

 Private residence relief on your home;

 Letting relief for a home previously lived in and subsequently rented;

 Entrepreneurs relief.

Private residence relief

Private residence relief is available for most people when they sell their home, meaning that they would not pay any capital gains tax upon sale.

If the above example was for an individual’s home, no capital gains tax would be payable, subject to meeting the relevant criteria. The main criteria is that the property and its grounds did not exceed ½ hectare (just over an acre) but also extends to there being no business premises and

other restrictions. It is relatively rare for one’s home to not qualify for full residence relief.

Letting relief

Letting relief arises where you owned a property and it was your home for part of the ownership period and subsequently rented out rather than disposed of when you vacated it.

This scenario allows you to claim private residence relief for the period of your occupancy plus letting relief for the last 18 months it was let out to a renter.

Letting relief is restricted to the lower of:

 The private residence relief;

 £40,000;

 Chargeable gain from letting your home.

Referring again to the original example, if the property had been the individual’s home for five years and subsequently rented out for five years, giving a combined ten-year ownership period, the capital gains tax payable would be little over £10,000.

It is important, therefore, that you keep good records and proof of when you lived in any properties that you continue to hold as investments.

Additionally, certain types of expenditure are added to the cost price within the calculations, such as structural alterations, so it is important that all invoices are retained, as it could be a long time before these details are required.

Entrepreneurs relief

Entrepreneurs relief is a way of substantially reducing the capital gains tax payable on the disposal of a business or business asset. For doctors carrying out a private practice, the most common application now is likely to be on the liquidation of their limited company.

If you are considering a voluntary liquidation of your limited company, it is extremely important that you discuss matters with your accountant, as criteria changed a couple of years ago restricting the application of this relief where a business has built up funds with a view to liquidation later on.

Your accountant should work with you to ensure that the most tax-efficient outcome is achieved.

Capital losses

Sometimes, a taxpayer will assume that if he or she is not making a profit, it doesn’t need to go on your tax return. Not so, capital losses can be stored up for potential future use against capital gains, provided that the criteria are met.

Residential property held in a company

We are currently in a transitional phase in relation to the tax deductibility of loan interest against rental income, which ultimately will result in many taxpayers paying more income tax on their rental properties.

This has led some to consider owning residential property within a limited company. It is important to note that new legislation targets high-value property – in excess of £500,000 – held within a limited company by charging an annual charge of corporation tax and also a higher rate

of capital gains tax being paid by the company.

If you are considering owning residential property through a company, it is important to consider whether you will be affected by this, as extraction of the property from the company later on can be particularly expensive.

Capital gains tax can be a complicated tax and often tax planning can be done in advance to mitigate the effect.

Make sure that when you are meeting with your accountant, you inform them of any future intentions, however remote, to ensure that any planning avenues can be explored.



Next month: A guide to capital allowances

Ian Tongue (right) is a partner with Sandison Easson accountants

The EV charges ahead

Dr Tony Rimmer turns over the engine of the new Nissan Leaf and finds it the most convincing

and reasonably priced electric car available

A successful business will only thrive by constantly looking to the future. As all independent practitioners know, identifying opportunities to attract more clients or run the practice more efficiently will help ensure long-term security.

new technologies often promise to provide these benefits and, if wisely pursued, can deliver great results.

i n the automotive world, it is the advancement of electric vehicles (eVs) that is gaining momentum and all manufacturers are developing new all-electric vehicles to stay competitive in our changing world.

One of the more affordable eVs is n issan’s l eaf, which was launched in 2011 and accounts for 47% of uK sales.

There is now a new second-generation l eaf and it offers more power, more tech, a new look and a slightly lower price. Most importantly, it offers more range from a

bigger 40kWh battery. l et’s see how it performs in the real world.

A VW Golf-sized hatchback, the original leaf was a slightly strange looking car; it was no looker. A 24kWh battery gave it a claimed range of over 120 miles, but in real day-to-day use, this was 80-90 miles. Things improved a bit in 2015 with the fitting of a 30kWh battery.

Greater appeal

The new model has been restyled completely and, i have to say, looks a lot better. i t has the appearance of a smart conventional five-door hatchback, which has greater appeal.

The single electric motor produces 148bhp, which is up from 107bhp. The battery is now 40kWh, which puts it on par with the VW e-Golf (36kWh) and Renault’s latest Zoe (41kWh).

claimed range from a full battery charge is 168 miles on the new Worldwide Harmonised

l ight Vehicle Test Procedure (W lTP) test, which is close to a real-world figure. f ull charging takes eight hours with a 7kWh home charger and only 40 minutes using a 50kWh fast charger.

There are four main trim levels: Visia, Acenta, n c onnecta and Tekna. s tandard features on all models include alloy wheels, airconditioning and a seven-inch multifunction touchscreen, Apple carplay and Android Auto.

The top-of-the-range Tekna features full leD lights, full-leather seats, a bose premium audio system and ProPilot.

ProPilot is a semi-autonomous driving aid that uses the adaptive cruise control, lane departure system and the e-Pedal regenerative braking system. u tilising regenerative braking to maximum effect, the e-Pedal allows driving just using the accelerator pedal. The brake pedal is only needed for more urgent or emergency stops.

Prices range from the £21,990

Visia up to £27,490 for the Tekna model. These are after the £4,500 government plug-in car grant. The new styling suits the l eaf and the interior now feels much more up to date. The seven-inch infotainment screen is easy to use and menu options include a readout of the main vehicle energy usage sources. This is great fun on any journey when trying to maximise the range.

Passengers in the rear get plenty of legroom, but because they are sitting above the battery pack, headroom is compromised. because the battery does not take any space from the boot, it is a very useful 435 litres.

Silent take-off

Driving an electric car is still a novelty. Rapid and silent take-off is the order of the day. Yes, the acceleration runs out of steam pretty quickly, but in the stopstart sub-30mph world of urban driving, the nippiness is addictive.

The new-style Leaf has been restyled completely and looks a lot better

Claimed range from a full battery charge is 168 miles on the new WLTP test

seven-inch

screen is easy to use and menu options include a readout of the main vehicle energy usage sources

I am impressed by it and any medic who is ready to take the electric-only plunge should give it a good look

in the leaf, this is magnified by the excellent e-Pedal system, which allows slowing to a stop without touching the brakes. i t doesn’t take long to adapt to driving completely with the use of the accelerator pedal alone. On the open road, it actually encourages a smoother driving approach – no bad thing.

Great improvement

Drive in a more spirited way, however, and you can watch the available range drop like a stone. At least the leAf is smooth and quiet on the motorway. Handling is pretty good but does not, obviously, encourage the sporty driver. The firm ride is generally good but can be fidgety over the rough stuff. i tried the ProPilot which generally works well, but relies on really clear white lines to function properly. i t is not as impressive or a well sorted as, for instance, Volvo’s Pilot Assist system.

The new leaf is a great improve-

ment over the previous model. n issan has made the best use of advanced driver-aid technology and, more importantly, included a bigger 40kWh battery to increase the useable range. it becomes, for the moment, the most convincing and reasonably priced electric car available. i am impressed by it and any medic who is ready to take the electriconly plunge should give it a good look.

However, until the real world driving range of electric cars gets up to 200–250 miles – as with expensive Teslas – the buying public will not embrace them fully. it won’t be long though. VW is soon to release an e-Golf with a 48kWh battery pack and all the major manufacturers are developing electric-only models, which will benefit from ground-up designs. 

Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey

2018 nIssan LeaF

Body: Five-door hatchback engine: single electric motor with 40kWh battery Power: 148bhp

Torque: 320nm

Top speed: 90mph (electronically limited)

acceleration: 0-60mph in 10.3 seconds

Claimed range: 168 miles (new WLTP test)

CO2 emissions: 0g/km

On-the-road price: £21,990 to £27,490 (includes £4,500 government grant)

The

infotainment

Full charging takes eight hours with a 7kWh home charger and only 40 minutes using a 50kWh fast charger

All

you

need to know about accountancy for private practitioners

pRoFiTs FocUs: dERmATologisTs

They’re in a healthy spot

Profits have again been on the rise for dermatologists and oncologists in our latest benchmarking survey, reports Ray Stanbridge

Our c O nclusi O ns last year (June 2017) were that the financial prospects for dermatologists were generally ‘very bright’.

Our latest survey suggests that perhaps results were not quite as good as they might have been.

The headline figures show that gross income increased by 3.8% from £129,000 to £134,000 between 2015 and 2016. costs rose on average by 4.3% from £46,000 to £48,000. As a result, taxable profits went up by £2,000 (3.6%) from £83,000 to £86,000.

They continue to benefit from both the ‘ditching’ of business from the nHs, and from self-pay work, and these are the primary reasons for their growth in income.

There has been little change in costs. staff salaries have increased by average from £16,000 to £17,000. As said before, there seems to be some correlation between the growth of family salaries and the tax-free personal allowance.

We have seen some increase in consulting room hire costs, probably as a result of an ever-stricter enforcement of the competition and Markets Authority rules –introduced in April 2015.

There was some decline in bad debt costs, while other costs have risen a little. Generally, these reflect the increasing spend the average dermatologist is incurring on marketing, websites and business promotions.

What of the future? Many dermatologists continue to do well, but there is an increasing interest in the ‘employment model’ for those with smaller practices.

Again, this will be a distorting factor when we are trying to look for trends. But i still believe that dermatology is a very promising area in private practice.

Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates

ouR cRItERIa foR SElEctIng conSultantS foR thE SuRvEy aRE that thEy muSt:

 have at least five years’ experience of the private sector

 have earned at least £5,000 gross in the private sector for the year starting 5 april 2016  have or have held an old-style nhS maximum or part-time contract

 be seriously interested in conducting private practice business

 work either as a sole trader through a limited liability partnership or group or through the medium of a limited liability firm

2015

dERmatologIStS’ coStS RISE kEPt PacE wIth thEIR IncomE IncREaSE

How ARE yoU doiNg?

A positive outlook

Income is going in the right direction for oncologists in Independent Practitioner Today’s unique benchmarking survey, finds Ray Stanbridge

A c OM plic AT i O n in trying to measure oncology income trends is that there are many ‘academic’ oncologists in relatively small private practices.

These distort average figures against those who have significant practices in an ever-growing market.

Headline figures show that on average, oncologist private practitioners income rose by 3% from £134,000 to £138,000 between 2015 and 2016.

costs went up by 2% between 2015 and 2016 from £43,000 to £45,000.

As a result, taxable profits rose by 3.2% from £91,000 to £93,000. s urprisingly, net margins also showed a slight increase from 67.9% to 68.2%.

chronic illness

i noted in my June 2017 report on this specialty that the ‘outlook for oncologists in private practice looks good and continues to be very positive’. i maintain this view. The fear is that insurers may start to look at some cancers as ‘chronic’ rather than ‘critical’ illness. This has thankfully not yet materialised – but watch this space.

i ncome growth seems to have been as a result of a concentration of more self-pay and more volume, despite squeezes on fee income by insurers.

staff costs have risen a little on average. similarly, there seems to have been a small increase in consulting room hire costs.

surprisingly, private indemnity insurance costs seem to have taken a modest fall. it looks as if that is down to new providers in the market place offering competitive deals.

Other costs are similar to the

previous year, save that there is continuing growth in marketing and promotion trends. i n this respect oncologists’ behaviour reflect that of their colleagues. c ancer is a growing problem and oncologists who are serious about private practice will continue to prosper.

recording reliable trends of private practice income of dermatologists and oncologists is, as stated in previous reports, difficult due

to a variety of factors including the mix of sole traders and the growth of different groups operating under a variety of trading structures.

Although profits Focus surveys are not statistically significant, they do however give an insight into current trends and demonstrate how incomes and spending are moving.

 Next time: general surgeons

tables and graphs, p56

use these benchmarks to compare

orthopaedic

years ending 5 april Source:

how dERmatologIStS and oncologIStS Stack uP

avERagE IncomE and ExPEndItuRE of a conSultant

Expenditure

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd.

ExPEnSES

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd.

what’s

coming in our JulY-august issue

make sure you don’t miss our next issue, published on 27 July. you may not receive every issue if you have not yet subscribed to the journal. don’t forget: subscribers can also read Independent Practitioner today as a page-turnable version on our website. don’t risk missing out on vital topics we tackle next month, including:

 Rocketing defence costs: we unpick a multi-million-pound compensation claim to see how much money is targeted for what, plus a look at doctors’ misunderstandings about their cover and how to ensure you have adequate protection for both professional and clinical practice

 bupa launches a new health insurance guide for doctors

 following new gmc guidance on supporting information for appraisal, mr Ian mackay, Responsible officer for the Independent doctors federation, runs through what you need to know

 ten years ago: our new regular feature highlights what was making the news in Independent Practitioner today back in 2008

 Reports from the Private healthcare Summit in london

 Self-pay: are you really managing your self-pay patient’s billing correctly?

 what you need to know to keep on track and stay on the right side of the taxman

 our PPu series hones in on what’s going on in East anglia

 would a mobile app make a difference for your practice? Plastic surgeon david floyd discusses why he provides an app for his patients, and how it improves the quality of information and care

EdItoRIal InQuIRIES

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Phone: 07909 997340

@robinstride

Published by The Independent Practitioner Ltd. Independent Practitioner

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write to

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 how best to manage your lawyer

 business dilemmas advises an anaesthetist confronting a dilemma when treating a patient who is a Jehovah’s witness

 our doctor on the Road motoring correspondent dr tony Rimmer on a charge with the volvo S90 t8 twin engine

 our ‘Start a Private Practice’ series looks at capital allowances

 when we should be saying no to treating clients – dr Sharan uppal (right), a gP-turnedaesthetic-doctor, gives her view

 top doctors: alberto Porciani, founder of top doctors, explains the rationale behind the development of the service

 Profits focus features the financial fortunes of general surgeons

 could you predict your life expectancy? dr benjamin holdsworth on preparing for a 40-year retirement

 our history of medicine series ends with ‘Quack Quack’ – the medical profession and a battle for the pennies of the poor

 top tips for busy doctors

 Plus all the latest news and views

advERtISERS: 29 June is the deadline for booking advertising in our July-august issue

advERtISIng InQuIRIES

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